Plain Chest Film Versus Computed Tomography of the Chest as the Initial Imaging Modality for Blunt Thoracic Injury.

BACKGROUND: While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma. METHODS: The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location. RESULTS: Propensity score matching yielded 17 716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups (P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178). DISCUSSION: CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments.

Pneumonectomy following penetrating trauma with ECMO as postoperative support: case report - (Lung trauma and ECMO).

BACKGROUND: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure. CASE DESCRIPTION: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery. CONCLUSIONS: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures.

BACKGROUND: Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. METHODS: A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. RESULTS: From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. CONCLUSION: Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. SYSTEMATIC REVIEW REGISTRATION: UMIN Clinical Trials Registry UMIN000049365.

Management of Blunt Chest Trauma.

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Validation of the 35-mm rule in traumatic pneumothorax in an Asian population.

OBJECTIVES: Thoracic injury crucially threatens human health. Recent studies have suggested using computed tomography (CT) to observe traumatic pneumothorax (PTX). However, cross-ethnic validation is required to overcome potential barriers for the global application of this method. This study aimed to validate the 35-mm rule in traumatic PTX in a Korean population. METHODS: Data from the institutional registry were analyzed, and chest CT images were reviewed. Factors for observation failure were evaluated via logistic regression analysis, and a receiver-operating curve was created to calculate the optimal cutoff value. RESULTS: In total, 286 participants were included in this study. The average PTX size was 8.2 (3.2-26.5) mm, and 210 of 213 (95.3%) initially observed patients with a PTX size of ≤35 mm successfully completed the safety observation. Multivariate regression analysis revealed that a PTX size of >35 mm is associated with observation failure and suggested a cutoff of 24.5 mm. CONCLUSION: Most patients with traumatic PTX of ≤35 mm on CT had undergone successful 4-h observation without thoracostomy. Additionally, PTX of >35 mm was an independent risk factor for observation failure. Considering the lower optimal cutoff value and high failure rates observed in this study, the current guidelines need modifications.

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis.

PURPOSE: This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. REVIEW METHODS: The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. RESULTS: Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. CONCLUSION: Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis.

The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury.

OBJECTIVE: Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. METHODS: Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. RESULTS: Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. CONCLUSIONS: Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.

Causes and Pattern of Chest Trauma Among Adults: A Scoping Review of Studies From the Middle East.

Chest trauma incidence is increasing worldwide, and it requires attention as it is a major cause of morbidity and mortality. Worldwide, chest trauma is the second most common cause of mortality and a major cause of disability and hospitalization. Our main aim is to systematically review the prevalence, pattern, causes, manner, morbidity, and mortality of chest trauma in the Middle East among adults. This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Screening of the relevant articles was done by using databases, including PubMed, Scopus, and Web of Science. A total of 128 articles were found as a result of searching the databases and reviewing the reference lists. Finally, nine articles met the inclusion criteria. Most of the victims were males, as reported by all studies in this systemic review. The most common cause of chest trauma was road traffic accident (RTA), as described in seven out of the nine included studies. The pattern of chest trauma included pneumothorax, hemothorax, hemopneumothorax, lung contusion, flail chest, rib fracture, and diaphragmatic injury. The rate of mortality and morbidity following chest trauma varied among the studies. However, most of the studies revealed higher rates of morbidity than mortality. Chest trauma carries economic and social burdens, and it is a serious issue, especially in males in the second to third decades. Preventive measures should be considered to decrease the prevalence of chest trauma and its related complications.

Management of a Transaxial, Tricompartmental Gunshot Injury in a Low-Resource Tertiary-Care Center in the Anglosphere Caribbean.

Trauma, both penetrating and blunt, consists of a significant percentage of surgical admissions in Caribbean hospitals. Due to financial constraints, ideal resources for optimal surgical management are not always available. Despite these disadvantages, successful outcomes for complex, emergent cases are achieved through a combination of timely clinical assessment, intervention, and ingenuity in using the resources at hand. In this case report, we describe a 17-year-old male who suffered major visceral injuries and presented in extremis from a single gunshot wound. While fleeing the scene of a crime, he was shot in his right pelvis, with the projectile exiting his left thorax. Injuries matching a transaxial gunshot trajectory that crossed the diaphragm and involved the pelvic, abdominal, and thoracic cavities were found on exploratory laparotomy. He survived through prompt surgical intervention and aggressive resuscitation during his postoperative intensivist care, a resource often unavailable in this setting. The patient's prognosis would have been guarded even in a developed country setting. This case highlights the potential that Caribbean healthcare institutes possess, and that given an improvement in resources, we can aim to match a developed country's standard of healthcare.