Can Concurrent Traumatic Hemopneumothorax be Safely Observed?

INTRODUCTION: The cooccurrence of a traumatic hemothorax (HTX) and pneumothorax (PTX) is extremely common (70%). Prior work shows the safety of observing small HTX (≤300 cubic centimeters) and PTX (≤35 mm) in isolation. Accordingly, we sought to assess the safety of observation of concurrent small hemopneumothorax(HPTX). METHODS: We conducted a single-center retrospective study from 2015 to 2021 at a level I trauma center. Patients with a computed tomography (CT) scan confirmed that HPTXwas included in the study. Exclusion criteria included tube thoracostomy (TT) prior to CT scan, TT placement for rib fixation, PTX>35 mm, HTX>300 cubic centimeters, and death within 72 h of admission. The study group was stratified into either initial observation or early TT, which is defined as TT placement immediately after initial CT scan. Primary outcome was observation failure. RESULTS: A total of 353 patients met the inclusion criteria, of whom 261 (74%) were initially observed. The initial observation cohort had a lower pulmonary morbidity rate (9% versus 14%; P = 0.04) and a shorter hospital (7 versus 10 d, P < 0.001) and intensive care unit (2 versus 4 d, P = 0.01) length of stay (LOS) when compared to those with initial TT placement. Sixty-eight (26%) patients failed observation, with a worsening HTXon repeat imaging (45%) being the most common reason. Compared to those who received an early TT, those who failed observation had a similar pulmonary morbidity and need for video-assisted thoracoscopic surgery, TT duration, LOS, readmission, and mortality rates. CONCLUSIONS: Initial observation of concurrent small traumatic HPTX had a lower pulmonary morbidity and LOS but was found to have a clinically significant failure rate. Patients who failed observation had similar outcomes to those who received an early TT.

Pectoralis Muscle Index as Predictor of Outcomes in Patients With Severe Blunt Chest Wall Injury.

INTRODUCTION: Sarcopenia has been shown to portend worse outcomes in injured patients; however, little is known about the impact of thoracic muscle wasting on outcomes of patients with chest wall injury. We hypothesized that reduced pectoralis muscle mass is associated with poor outcomes in patients with severe blunt chest wall injury. METHODS: All patients admitted to the intensive care unit between 2014 and 2019 with blunt chest wall injury requiring mechanical ventilation were retrospectively identified. Blunt chest wall injury was defined as the presence of one or more rib fractures as a result of blunt injury mechanism. Exclusion criteria included lack of admission computed tomography imaging, penetrating trauma, <18 y of age, and primary neurologic injury. Thoracic musculature was assessed by measuring pectoralis muscle cross-sectional area (cm2) that was obtained at the fourth thoracic vertebral level using Slice-O-Matic software. The area was then divided by the patient height in meters2 to calculate pectoralis muscle index (PMI) (cm2/m2). Patients were divided into two groups, 1) the lowest gender-specific quartile of PMI and 2) second-fourth gender-specific PMI quartiles for comparative analysis. RESULTS: One hundred fifty-three patients met the inclusion criteria with a median (interquartile range) age 48 y (34-60), body mass index of 30.1 kg/m2 (24.9-34.6), and rib score of 3.0 (2.0-4.0). Seventy-five percent of patients (116/153) were male. Fourteen patients (8%) had prior history of chronic lung disease. Median (IQR) intensive care unit length-of-stay and duration of mechanical ventilation (MV) was 18.0 d (13.0-25.0) and 15.0 d (10.0-21.0), respectively. Seventy-three patients (48%) underwent tracheostomy and nine patients (6%) expired during hospitalization. On multivariate linear regression, reduced pectoralis muscle mass was associated with increased MV duration when adjusting for rib score and injury severity score (ß 5.98, 95% confidence interval 1.28-10.68, P = 0.013). CONCLUSIONS: Reduced pectoralis muscle mass is associated with increased duration of MV in patients with severe blunt chest wall injury. Knowledge of this can help guide future research and risk stratification of critically ill chest wall injury patients.

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

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

The effect of thoracic trauma scoring system in thoracic trauma patients with rib fracture.

OBJECTIVE: Rib fractures are common in thoracic trauma patients. There are various factors, including flail chest, pulmonary contusion, and accompanying conditions, affecting morbidity and mortality. The study aimed to identify high-risk patients for morbidity and mortality with a scoring system that the authors created. METHODS: Cases over the age of 18 admitted due to trauma and diagnosed with rib fractures between 1 January 2019 and 1 March 2023, were included. Trauma scores were determined by applying the new trauma scoring system. Trauma scores and other variables regarding morbidity and mortality were evaluated. RESULTS: A total of 1023 cases were included in the study. The total trauma scores were higher in bilateral and multiple fractures. In those without respiratory failure, the total score was statistically significantly lower than in the groups with respiratory failure. The total score was significantly higher in those who needed surgery, those who were hospitalized, and those who needed intensive care compared to the non-surgical groups. However, there was no correlation between intensive care unit stay and total score. Trauma mechanism, presence of additional extrathoracic pathology, and thoracic trauma-age score were independent predictors of survival. CONCLUSION: The present study demonstrated that the number of rib fractures and the presence of pulmonary contusion did not have an effect on mortality and morbidity. The presence of extrathoracic pathology and age significantly affect survival.

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma.

INTRODUCTION: Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT. METHODS: We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality. RESULTS: A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02). CONCLUSIONS: The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review.

Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.

Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands.

Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7-14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2-8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. CONCLUSION: Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution. WHAT IS KNOWN: • Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality. • Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures. WHAT IS NEW: • The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death. • The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma.

Management of thoracic trauma.

Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report.

BACKGROUND: Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures. METHODS: Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation. RESULTS: Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment. CONCLUSIONS: Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

Effect of chest ultrasound compared with pericardial window for the diagnosis of occult penetrating cardiac wounds in hemodynamically stable subjects with penetrating thoracic trauma: A meta-analysis.

We conducted a meta-analysis to assess the diagnostic performance of chest ultrasound compared with a pericardial window for the detection of occult penetrating cardiac wounds in patients with penetrating thoracic trauma who were hemodynamically stable. A systematic literature search up to December 2022 was performed and 567 related studies were evaluated. The chosen studies comprised 629 penetrating thoracic trauma subjects who participated in the selected studies' baseline. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of different chest ultrasounds on wound infection after penetrating thoracic trauma by the dichotomous methods with a random or fixed effect model. The chest ultrasound resulted in significantly lower occult penetrating cardiac wounds detection (OR, 0.02; 95% CI, 0.01-0.08, P < 0.001), higher false positive (OR, 33.85; 95% CI, 9.21-124.39, P < 0.001), and higher false negative (OR, 27.31; 95% CI, 7.62-97.86, P < 0.001) compared with the pericardial window in penetrating thoracic trauma. The chest ultrasound resulted in significantly lower occult penetrating cardiac wound detection, higher false positives, and higher false negatives compared with the pericardial window in penetrating thoracic trauma. Although care should be taken when dealing with the results because all of the studies had less than 200 subjects as a sample size.

Evaluating the Need for Prolonged Telemetry Monitoring in Patients With Isolated Sternal Fractures.

INTRODUCTION: Isolated sternal fractures (ISFs) often result from deceleration or chest wall trauma. Current guidelines recommend screening ISF patients for blunt cardiac injury (BCI) with electrocardiogram (ECG) and troponin. If either is abnormal, 24-h telemetry monitoring is recommended. This study sought to determine if ISF patients with abnormal ECG will manifest any cardiac-related complications within 6 h of hospital arrival. METHODS: A retrospective study was performed at a single level I trauma center. Patients with diagnosed sternal fracture and an Abbreviated Injury Scale <2 for head/neck, face, abdomen, and extremities were included. Patients with multiple rib fractures or hemopneumothorax were excluded. Demographic data, ECG, troponin, and echocardiogram results were collected. The primary outcome was cardiac-related complications or procedures. Complications included hypotension, arrhythmia, and hemodynamic instability. Procedures included sternal stabilization, cardiac catheterization, or sternotomy/thoracotomy. Descriptive statistics were performed. RESULTS: One hundred twenty-nine ISF patients were evaluated, 68 (52.7%) had an ECG abnormality. Eight patients had elevated troponin (6.2%). One patient (0.78%) suffered a cardiac-related complication (arrhythmia); however, this was 82 h into hospitalization. Two patients suffered noncardiac complications (urinary tract infection and acute kidney injury) (1.55%). Three patients had echocardiogram abnormality (2.33%), but no patients sustained a BCI or underwent a BCI-related procedure. CONCLUSIONS: After ISF, <1% of patients suffered a cardiac-related complication and none had BCI. These findings suggest 24-h monitoring for patients with ISF and abnormal ECG may be unnecessarily long. A prospective multicenter study to evaluate the validity of these results is needed prior to change of practice.

Elevated Serum Interleukin-17 Levels in Thoracic Trauma Patients with Poor Prognosis: A Prospective Observational Study.

PURPOSE: To measure interleukin (IL)-17 serum levels in thoracic trauma patients and to correlate these levels with other cytokines and with patient prognosis.  Methods: This prospective observational study recruited 130 thoracic trauma patients who were admitted to the Zhoupu Hospital Affiliated to Shanghai Medical College of Health June 2020 to April 2022 and 100 healthy volunteers. Patients were divided into two groups based on Injury Severity Score (ISS): ISS<16 (mild/moderate trauma) and ISS ≥16 (severe trauma). Serum IL-17, tumor necrosis factor α (TNF-α), IL-6, IL-1ß and C-reactive protein (CRP) levels were measured by enzyme-linked immunosorbent assay. Patients with poor prognosis were defined as those who developed serious complications or died during hospitalization or follow-up.  Results: Serum levels of IL-17, TNF-α, IL-6 and IL-1ß were significantly elevated in patients with ISS ≥16 (p<0.05). Serum cytokines levels increased within 48 h in both groups and then gradually decreased during subsequent treatment and rehabilitation. Pearson's analysis indicated a positive correlation among IL-17, TNF-α and IL-1ß. Serum IL-17 levels in patients with poor prognoses were higher than the patients with good prognoses at all time points (p<0.05). Furthermore, for patients with poor prognoses, the serum IL-17 levels had highest diagnostic value among all the cytokines measured. Logistic regression analysis showed that IL-17 was the risk factor for thoracic trauma patients with poor prognoses.  Conclusion: Serum IL-17 levels were significantly elevated in thoracic trauma patients and decreased gradually with rehabilitation. IL-17 was a risk factor for thoracic trauma patients with poor prognoses. This study suggests a new diagnostic and therapeutic target for thoracic trauma patients.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®.

INTRODUCTION: Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis. MATERIAL AND METHODS: Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test. RESULTS: Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%). CONCLUSIONS: In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

Perforation of the right cardiac ventricle as a late complication of a displaced sternal fracture following blunt trauma.

Cardiac tamponade is a rare but possibly fatal complication of blunt thoracic trauma complicated by a sternal fracture. A delayed presentation of cardiac tamponade days or weeks after initial trauma has been described in a few cases. In these cases, the presumed mechanism of cardiac tamponade is pericardial irritation, caused by osseous fragments of the fractured sternum. This case describes a direct mechanical perforation of the right ventricle, caused by a displaced sternal fracture, presenting 5 days after initial trauma. To our knowledge, this mechanism of late cardiac tamponade has not been described in recent literature.

The use of ultrasound in establishing COVID-19 infection as part of a trauma evaluation.

PURPOSE: The use of lung ultrasound for diagnosis of COVID-19 has emerged during the pandemic as a beneficial diagnostic modality due to its rapid availability, bedside use, and lack of radiation. This study aimed to determine if routine ultrasound (US) imaging of the lungs of trauma patients with COVID-19 infections who undergo extended focused assessment with sonography for trauma (EFAST) correlates with computed tomography (CT) imaging and X-ray findings, as previously reported in other populations. METHODS: This was a prospective, observational feasibility study performed at two level 1 trauma centers. US, CT, and X-ray imaging were retrospectively reviewed by a surgical trainee and a board-certified radiologist to determine any correlation of imaging findings in patients with active COVID-19 infection. RESULTS: There were 53 patients with lung US images from EFAST available for evaluation and COVID-19 testing. The overall COVID-19 positivity rate was 7.5%. COVID-19 infection was accurately identified by one patient on US by the trainee, but there was a 15.1% false-positive rate for infection based on the radiologist examination. CONCLUSIONS: Evaluation of the lung during EFAST cannot be used in the trauma setting to identify patients with active COVID-19 infection or to stratify patients as high or low risk of infection. This is likely due to differences in lung imaging technique and the presence of concomitant thoracic injury.

Obesity Protects Against Operation in Pediatric Penetrating Trauma to the Torso.

BACKGROUND: Studies in the adult population are conflicting regarding whether obesity is protective in penetrating trauma. In the pediatric population, data on obesity and penetrating trauma are limited. We sought to determine if there is a different rate of operation or of survival in pediatric and adolescent patients with obesity. METHODS: We queried the National Trauma Data Bank research data set from 2013 to 2016 for all patients aged 2-18 who sustained traumatic penetrating injuries to the thorax and abdomen. The cohort was divided into body mass index percentiles for gender and age using Center for Disease Control definitions. Outcomes included overall survival, whether or not an operative procedure was performed, and hospital and intensive care unit (ICU) length of stay. RESULTS: We analyzed 9611 patients with penetrating trauma, of which 4285 had an operative intervention. When adjusted for other variables (age, gender, race, ICU length of stay, hospital length of stay, and Injury Severity Score), children of every body mass index percentile had similar survival. Healthy weight patients were more likely to get an operation than patients in the obese category. Length of hospital stay was similar between groups, but the ICU length of stay was longer in the overweight and obese groups compared with healthy weight and underweight groups. CONCLUSIONS: Children and adolescents with obesity are less likely to undergo operation after penetrating thoracoabdominal trauma. Further study is needed to determine the reason for this difference.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma.

BACKGROUND: Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma. MATERIALS AND METHODS: Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups. RESULTS: Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge. CONCLUSIONS: The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality.

BACKGROUND: Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. MATERIALS AND METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. RESULTS: From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. CONCLUSIONS: The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

Making Ventilator Associated Pneumonia Rate a Meaningful Quality Marker.

INTRODUCTION: Ventilator associated pneumonia (VAP) rate has been tracked as a comparable quality measure but there is significant variation between types of ICUs. We sought to understand variability and improve its utility as a marker of quality. METHODS: The National Trauma Database was surveyed to identify risk factors for VAP. Logistic regression, χ2, Student's T-test or Mann-Whitney U test were used. RESULTS: Risk factors associated with developing VAP were: injury severity score (ISS) (OR 1.03, 95% CI 1.03 -1.04), prehospital assisted respiration (PHAR) (OR 1.10, 1.03 -1.17), thoracic injuries (OR 2.28, 1.69-3.08), diabetes (OR 1.32, 1.20 -1.46), male gender (OR 1.38, 1.28 -1.60), care at a teaching hospital (OR 1.40, 1.29 -1.47) and unplanned intubation (OR 2.76, 2.52-3.03). DISCUSSION: ISS, PHAR, diabetes, male gender, care at a teaching hospital and unplanned intubation are risk factors for the development of VAP. These factors should be accounted for in order to make VAP an effective quality marker.

Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review.

Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.