Blunt-chest-trauma-induced acute myocardial infarction

Blunt chest trauma (BCT) is one of the rarest causes of acute myocardial infarction (AMI). This paper reports the case of a young married man who suffered from AMI due to BCT sustained in a fight with his wife. The histopathology examination revealed a rupture of atherosclerotic plaque with superimposed thrombus in the proximal left anterior descending artery. This report also reviews previously reported BCT-induced AMI cases in the literature.

Myocardial tissue embolism in lung due to gunshot wound to the chest.

Myocardial tissue embolism due to gunshot wound is a very rare event, as only a few cases of myocardial tissue embolization, occurring after cardiac surgery or myocardial infarction, have been reported. According to this study's referenced report from forensic autopsy, one case of myocardial tissue emboli to the lung has been found, in an Asian male, 22 years old, who died from a gunshot to the chest by a handgun. From the examination, myocardial tissue embolism was considered important forensic evidence, showing that the gunshot occurred while the victim was still alive, and that he also survived for some period of time after being shot.

Contributing factors in the development of acute lung injury in a murine double hit model.

OBJECTIVES: Blunt chest (thoracic) trauma (TxT) is known to contribute to the development of secondary pulmonary complications. Of these, acute lung injury (ALI) is common especially in multiply injured patients and might not only be due to the direct trauma itself, but seems to be caused by ongoing and multifactorial inflammatory changes. Nevertheless, the exact mechanisms and contributing factors of the development of ALI following blunt chest trauma are still elusive. METHODS: 60 CL57BL/6N mice sustained either blunt chest trauma combined with laparotomy without further interventions or a double hit (DH) including TxT and cecal ligation puncture (CLP) after 24 h to induce ALI. Animals were killed either 6 or 24 h after the second procedure. Pulmonary expression of inflammatory mediators cxcl1, cxcl5, IL-1ß and IL-6, neutrophil infiltration and lung tissue damage using the Lung Injury Score (LIS) were determined. RESULTS: Next to a moderate increase in other inflammatory mediators, a significant increase in CXCL1, neutrophil infiltration and lung injury was observed early after TxT, which returned to baseline levels after 24 h. DH induced significantly increased gene expression of cxcl1, cxcl5, IL-1ß and IL-6 after 6 h, which was followed by the postponed significant increase in the protein expression after 24 h compared to controls. Neutrophil infiltration was significantly enhanced 24 h after DH compared to all other groups, and exerted a slight decline after 24 h. LIS has shown a significant increase after both 6 and 24 h compared to both control groups as well the late TxT group. CONCLUSION: Early observed lung injury with moderate inflammatory changes after blunt chest trauma recovered quickly, and therefore, may be caused by mechanical lung injury. In contrast, lung injury in the ALI group did not undergo recovery and is closely associated with significant changes of inflammatory mediators. This model may be used for further examinations of contributing factors and therapeutic strategies to prevent ALI.

Synthetic tracheal grafts seeded with bone marrow cells fail to generate functional tracheae: First long-term follow-up study.

OBJECTIVE: Synthetic tracheal grafts seeded with autologous bone marrow-mononuclear cells (BM-MNCs) have been described as becoming living and functional grafts representing a promising option for tracheal replacement for pathologies unamenable by segmental resection or autologous repair. This study aimed to present the first long-term follow-up of these procedures in humans. METHODS: We retrospectively analyzed 3 patients who received synthetic tracheal grafts seeded with BM-MNCs implanted. RESULTS: Patient 1 was a 37-year-old man with mucoepidermoid carcinoma, the first-ever human to receive a synthetic tracheal graft seeded with BM-MNCs. Patient 2 was a 30-year-old man with adenoid cystic carcinoma, and patient 3 was a 22-year-old woman with an iatrogenic tracheal injury. All patients developed graft-related complications necessitating multiple surgical reinterventions. Patient 1 was hospitalized for 8 months before dying from respiratory failure secondary to graft dehiscence 32 months after implantation. Patient 2 died 3.5 months after implantation from undisclosed causes. Patient 3 received a second synthetic tracheal graft after 11 months and an allogeneic trachea and lung transplantation 45 months after the primary implantation. Patient 3 underwent 191 surgical interventions after the primary implantation and spent 55 months in the intensive care unit before dying from airway bleeding. All patients' bronchoscopic, histologic, and radiologic investigations demonstrated graft-associated complications, including anastomotic fistulae and obstructive granulation tissue, without graft vascularization, mucosal lining, or integration into adjacent tissues. CONCLUSIONS: Synthetic tracheal grafts seeded with BM-MNCs do not become living functional tracheal grafts and lead to debilitating complications and death.

Association between computed tomographic thoracic injury scores and blood gas and acid-base balance in dogs with blunt thoracic trauma.

OBJECTIVE: To determine the association between thoracic injuries evaluated by computed tomography (CT) and arterial blood gas and acid-base status in dogs with blunt thoracic trauma caused by motor vehicle accidents. DESIGN: Prospective observational clinical study. SETTING: University teaching hospital. ANIMALS: Thirty-one client owned traumatized dogs and 15 healthy dogs. PROCEDURES: All trauma group dogs underwent a CT scan and simultaneous arterial blood gas analysis within 24 hours, but not before 4 hours, after the traumatic incident within a 45-month enrollment period. MEASUREMENTS AND MAIN RESULTS: Thorax injuries were classified as pulmonary, pleural space, or rib cage and each of these components was scored for severity using a CT composite pulmonary, pleural, and rib score. The trauma group arterial blood gas and acid-base status were evaluated for statistical difference from the control group. The pulmonary-arterial oxygen pressure was significantly lower in the trauma group compared to the control group that was supported by significant differences in the calculated variables of arterial blood oxygenation as well. There was also a significant correlation between the composite lung score and pleural score and the variables of arterial oxygen status. The pulmonary-arterial carbon dioxide pressure was not significantly different to any of the thoracic injury variables indicating normal alveolar ventilation. Acid-base imbalances were generally mild, insignificant, and variable. CONCLUSIONS AND CLINICAL RELEVANCE: Blunt thoracic trauma causes significant pulmonary and pleural injury and the blood oxygen economy is significantly affected by this. The functional measures of arterial blood oxygenation were well correlated with thoracic CT pathology. Alveolar ventilation was mostly spared but a clinically significant ventilation perfusion mismatch was present.

Life-saving emergency clamshell thoracotomy with damage-control laparotomy.

Clamshell thoracotomy for thoracic injuries is an uncommon emergency department procedure. The survival rates following emergency thoracotomy are very low at 9%-12% for penetrating trauma and 1%-2% for blunt trauma. We report an unusual case of survival after emergency department clamshell thoracotomy for penetrating thoracic trauma with cardiac tamponade in a 23-year-old man with multiple stab wounds on the chest and abdomen. The patient was awake and alert on arrival in the emergency department. Bilateral chest decompression by needle thoracostomy released air and blood. During subsequent chest drain insertion, the patient suddenly deteriorated and arrested. Clamshell thoracotomy was performed, and sinus rhythm restored before transfer to theatre. Following repair of the thoracic injuries, a midline laparotomy was performed as bleeding was suspected from the abdomen and a splenic injury repaired. The patient survived and has made a full recovery. This case demonstrates how clamshell thoracotomy can be a life-saving procedure.

Burn and thoracic trauma alters fracture healing, systemic inflammation, and leukocyte kinetics in a rat model of polytrauma.

BACKGROUND: Singular traumatic insults, such as bone fracture, typically initiate an appropriate immune response necessary to restore the host to pre-insult homeostasis with limited damage to self. However, multiple concurrent insults, such as a combination of fracture, blunt force trauma, and burns (polytrauma), are clinically perceived to result in abnormal immune response leading to inadequate healing and resolution. To investigate this phenomenon, we created a model rat model of polytrauma. METHODS: To investigate relationship between polytrauma and delayed healing, we created a novel model of polytrauma in a rat which encompassed a 3-mm osteotomy, blunt chest trauma, and full-thickness scald burn. Healing outcomes were determined at 5 weeks where the degree of bone formation at the osteotomy site of polytrauma animals was compared to osteotomy only animals (OST). RESULTS: We observed significant differences in the bone volume fraction between polytrauma and OST animals indicating that polytrauma negatively effects wound healing. Polytrauma animals also displayed a significant decrease in their ability to return to pre-injury weight compared to osteotomy animals. Polytrauma animals also exhibited significantly altered gene expression in osteogenic pathways as well as the innate and adaptive immune response. Perturbed inflammation was observed in the polytrauma group compared to the osteotomy group as evidenced by significantly altered white blood cell (WBC) profiles and significantly elevated plasma high-mobility group box 1 protein (HMGB1) at 6 and 24 h post-trauma. Conversely, polytrauma animals exhibited significantly lower concentrations of plasma TNF-alpha (TNF-α) and interleukin 6 (IL-6) at 72 h post-injury compared to OST. CONCLUSIONS: Following polytrauma with burn injury, the local and systemic immune response is divergent from the immune response following a less severe singular injury (osteotomy). This altered immune response that follows was associated with a reduced capacity for wound healing.

Horticultural Homicide: Stab Wound to the Chest Masquerading as Impalement by Rose Bush.

Instruments that create stab wounds are required to possess tips of sufficient strength and rigidity to breach the integrity of the skin. Knives, the most common weapons used to create stab wounds, have cutting edges that cleave the skin, leaving unabraded margins. On rare occasions, blunt objects are driven with sufficient force to pierce the skin and become impaled within the body. The morphologic differences between the cutaneous injuries and wound tracks of stab wounds from sharp objects and impalement with blunt ones provide clear delineation of the two. However, elements from the scene and obscuring hemorrhage can make initial differentiation difficult. The authors report the death of a 59-year-old woman found near the entryway steps of her home with a stab wound to her chest. Law enforcement did not discover any weapons. Investigation focused on blood around and on a broken rose bush planted near the steps with the belief that the decedent had fallen upon the vegetation. When presented with information that conflicts with autopsy findings, careful consideration of proposed weapons and thorough examination of the wound are required to discount confounding material.

Systemic recovery and therapeutic effects of transplanted allogenic and xenogenic mesenchymal stromal cells in a rat blunt chest trauma model.

BACKGROUND: Effective therapy of Acute Lung Injury (ALI) is still a major scientific and clinical problem. To define novel therapeutic strategies for sequelae of blunt chest trauma (TxT) like ALI/Acute Respiratory Distress Syndrome, we have investigated the immunomodulatory and regenerative effects of a single dose of ex vivo expanded human or rat mesenchymal stromal cells (hMSCs/rMSCs) with or without priming, immediately after the induction of TxT in Wistar rats. METHODS: We analyzed the histological score of lung injury, the cell count of the broncho alveolar lavage fluid (BAL), the change in local and systemic cytokine level and the recovery of the administered cells 24 h and 5 days post trauma. RESULTS: The treatment with hMSCs reduced the injury score 24 h after trauma by at least 50% compared with TxT rats without MSCs. In general, TxT rats treated with hMSCs exhibited a lower level of pro-inflammatory cytokines (interleukin [IL]-1B, IL-6) and chemokines (C-X-C motif chemokine ligand 1 [CXCL1], C-C motif chemokine ligand 2 [CCL2]), but a higher tumor necrosis factor alpha induced protein 6 (TNFAIP6) level in the BAL compared with TxT rats after 24 h. Five days after trauma, cytokine levels and the distribution of inflammatory cells were similar to sham rats. In contrast, the treatment with rMSCs did not reveal such therapeutic effects on the injury score and cytokine levels, except for TNFAIP6 level. CONCLUSION: TxT represents a suitable model to study effects of MSCs as an acute treatment strategy after trauma. However, the source of MSCs has to be carefully considered in the design of future studies.

A new multiple trauma model of the mouse.

BACKGROUND: Blunt trauma is the most frequent mechanism of injury in multiple trauma, commonly resulting from road traffic collisions or falls. Two of the most frequent injuries in patients with multiple trauma are chest trauma and extremity fracture. Several trauma mouse models combine chest trauma and head injury, but no trauma mouse model to date includes the combination of long bone fractures and chest trauma. Outcome is essentially determined by the combination of these injuries. In this study, we attempted to establish a reproducible novel multiple trauma model in mice that combines blunt trauma, major injuries and simple practicability. METHODS: Ninety-six male C57BL/6 N mice (n = 8/group) were subjected to trauma for isolated femur fracture and a combination of femur fracture and chest injury. Serum samples of mice were obtained by heart puncture at defined time points of 0 h (hour), 6 h, 12 h, 24 h, 3 d (days), and 7 d. RESULTS: A tendency toward reduced weight and temperature was observed at 24 h after chest trauma and femur fracture. Blood analyses revealed a decrease in hemoglobin during the first 24 h after trauma. Some animals were killed by heart puncture immediately after chest contusion; these animals showed the most severe lung contusion and hemorrhage. The extent of structural lung injury varied in different mice but was evident in all animals. Representative H&E-stained (Haematoxylin and Eosin-stained) paraffin lung sections of mice with multiple trauma revealed hemorrhage and an inflammatory immune response. Plasma samples of mice with chest trauma and femur fracture showed an up-regulation of IL-1ß (Interleukin-1ß), IL-6, IL-10, IL-12p70 and TNF-α (Tumor necrosis factor- α) compared with the control group. Mice with femur fracture and chest trauma showed a significant up-regulation of IL-6 compared to group with isolated femur fracture. CONCLUSIONS: The multiple trauma mouse model comprising chest trauma and femur fracture enables many analogies to clinical cases of multiple trauma in humans and demonstrates associated characteristic clinical and pathophysiological changes. This model is easy to perform, is economical and can be used for further research examining specific immunological questions.

Thoracic trauma now and then: A 10 year experience from 16,773 severely injured patients.

BACKGROUND AND PURPOSE: Thoracic trauma remains to be a relevant injury to the polytraumatised patient. However, literature regarding how far changes in clinical guidelines for pre- and in-hospital trauma management and diagnostic procedures affect the outcome of multiple injured patients with severe chest injury during a long-term observation period is sparse. METHODS: Multiple traumatised patients (age≥16y) documented in the TraumaRegister DGU® (TR-DGU) from January 1st 2005 to December 31st 2014 with severe chest trauma (AIS≥3) were included in this study. Demographic data, the pattern of injury, injury severity, radiographic emergency procedures, indication for intubation, duration of mechanical ventilation, emergency surgery, occurrence of complications and mortality were evaluated per year and over time. RESULTS: A total of 16,773 patients were analysed. The use of whole body computer tomography increased (p<0.001), while the incidence of plain x-rays decreased (p<0.001). Furthermore, incidence of AISThorax = 3 graded injuries increased (p<0.001) while AISThorax = 4 decreased (p<0.001). Both, rate of patients being intubated at the time of ICU admission decreased (p<0.001) and the time of mechanical ventilation decreased (p<0.001). Additionally, need for emergency surgery, lung failure, sepsis, and multi organ failure all decreased (p<0.001). However, mortality remained unchanged. INTERPRETATION: Severity of severe chest trauma and associated complications decreased while diagnostics and treatment improved over time. However, mortality remained unchanged. Our results are in line with those expected in the context of the incidence of CT diagnostics, which has increased parallel to the clinical outcome Thus, our data demonstrate a positive trend in the treatment of patients with severe chest trauma.

[THE METHOD CHOICE OF OPERATIVE INTERVENTION IN PATIENTS WITH POSTTRAUMATIC DEFECTS OF COVERING TISSUES OF TRUNK AND EXTREMITIES].

Results of 242 patients treatment, suffering the trunk and extremities covering tissues defects, which have had occur as a consequence of mechanical injury in a 2008 ­ 2016 yrs period, were analyzed. There were 697 оperative interventions performed, of them 492 (70.6%) ­ aiming to restore the tissues injured. The choice of method of the correcting intervention and the tissues defects covering have depended upon the wound dimension and depth, as well as peculiarities of hemodynamics in the area injured. Application of differentiated approach to choice of method for the wound surfaces closure, which were created as a consequence of mechanical injury, have had permitted to achieve satisfactory results in 98.75% of patients.

On-scene factors that predict severe injury of patients involved in frontal crashes of passenger cars.

PURPOSE: We sought to determine on-scene factors that predict severe injury to the occupants of passenger cars involved in frontal crashes. METHODS: From January 2011 to December 2014, we collected data from patients who were taken to two emergency centres following a frontal motor vehicle crash. Binomial logistic regression was used to model the effects of occupant characteristics (sex, age, body mass index), vehicle damage (according to the collision deformation classification code), and safety devices on severe injuries (injury severity score >15). RESULTS: Of 344 subjects, 75 (21.8 %) had severe injuries. Sex, seat belt status, extent of vertical crash, intrusion, and deformation extent (DE) were significantly different between severe and non-severe injuries. After adjusting for confounders, non-use of seat belt tripled the odds of severe injury [odds ratio (OR) 2.7, 95 % confidence interval (CI) 1.461-5.105]. DE ≥4 and intrusion increased the risk of severe injury (OR 2.4, 95 % CI 1.120-5.204 and OR 5.2, 95 % CI 2.525-10.780, respectively). A combination model to predict severe injury using intrusion, seat belt use, and DE ≥4 demonstrated 56.0 % sensitivity, 88.9 % specificity, and 58.4 % positive predictive value (AUC = 0.781, 95 % CI 0.734-0.824). CONCLUSIONS: For passenger cars involved in a frontal crash, intrusion, unbelted status, and DE ≥4 are good predictors of severe injury. Sequential criteria using vehicle DE, seat belt use, and intrusion can be used by first responders to triage patients involved in a frontal collision.

Traumatic aortic injury: does the anatomy of the aortic arch influence aortic trauma severity?

PURPOSE: Traumatic aortic injury (TAI) is a rare but life-threatening type of injury. We investigate whether the anatomy of the aortic arch influences the severity of aortic injury. METHODS: This is a retrospective study of twenty-two cases treated with TEVAR for TAI in our department from 2009 to 2014. Aortic injury was assessed in accordance with the recommendations of the Society of Vascular Surgery. We measured the aortic arch angle and the aortic arch index, based on the initial angio-CT scan, in each of the analyzed cases. RESULTS: The mean aortic arch index and mean aortic arch angle were 6.8 cm and 58.3°, respectively, in the type I injury group; 4.4 cm and 45.9° in the type III group; 3.3 cm and 37° in the type IV group. There were substantial differences in both the aortic arch index and the aortic arch angle of the type III and IV groups. A multivariate analysis confirmed that the aortic arch angle was significantly associated with the occurrence of type III damage (OR 1.5; 95% CI 1.03-2.2). CONCLUSIONS: The severity of TAI is influenced by the sharpness of the aortic arch. There is an inverse relationship between the severity of aortic injury and the aortic arch index.

Traumatic pulmonary pseudocyst: An underreported entity.

BACKGROUND: Traumatic pulmonary pseudocysts (TPP) are underreported cavitary lesions of the pulmonary parenchyma that can develop following blunt chest trauma. Although the occurrence of traumatic pulmonary pseudocyst is rare, this condition should be considered in the differential diagnosis of any cavitary lesion. Awareness of this injury and its clinical significance is important for successful management in order to avoid medical errors in the course of treatment. METHODS: A literature search was conducted through Medline using the key phrases "traumatic pulmonary pseudocyst" and "traumatic pneumatocele." Relevant articles, especially those with focus on diagnosis and management of traumatic pneumatocele in adults, were selected. Due to the scarcity of literature and lack of Level I evidence on this subject, studies published in any year were considered. RESULTS: A search of "traumatic pulmonary pseudocyst" and "traumatic pneumatocele" yielded 114 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were reviewed. The majority of these were individual case studies; only eight articles were considered large case studies (greater than eight patients). CONCLUSION: Traumatic pulmonary pseudocysts are lesions that occur secondary to blunt chest trauma. Diagnosis is based on a history of trauma and appearance of a cystic lesion on CT. Accurate diagnosis of traumatic pulmonary pseudocyst is imperative to achieve successful outcomes. Failure to do so may lead to unnecessary procedures and complications.

The effect of body mass index on trauma severity and prognosis in trauma patients.

BACKGROUND: As in the rest of the world, the prevalence of obesity in Turkey has been increasing in recent years and has become a major public health issue. Although many trials have been conducted to study the effects of obesity on internal diseases, there are few studies investigating the effects of obesity on prognosis of trauma patients. The present study analyzed the effects of body mass index (BMI) on trauma severity and prognosis in trauma patients. METHODS: This study was prospectively conducted with trauma patients older than 15 years of age who presented at the Dicle University Faculty of Medicine emergency medicine department trauma unit between June 1, 2013 and May 31, 2014. Patients were grouped into high-energy trauma and low-energy trauma groups based on trauma severity. In addition, 4 groups were made according to BMI value (kg/m2). Group I was defined as BMI <25 (normal weight). Group II patients had BMI of 25-29.9 (overweight). Group III had BMI of 30-34.9 (obese), and Group IV was made up of patients with BMI ≥35 (morbidly obese). RESULTS: Comparison of whole patient population for inter-group differences showed significant differences between rate of head injury, thoracic injury, extremity injury, multitrauma, clinic admission rate, and mortality rate (p<0.001). No significant difference was observed between groups in abdominal injury rate (p=0.347). CONCLUSION: Clinic admission rate, length of intensive care unit stay, mortality rate, multitrauma rate, and injury severity score increased in proportion to greater BMI.

Scintigraphic Diagnosis of Intrathoracic Splenic Implants Masquerading as Malignancy.

After significant trauma to the spleen, small viable splenic fragments may exist in the peritoneal cavity or, less commonly, in the thorax. Thus, the appearance of splenules within the thorax on CT images can easily be mistaken for malignancy and lead to unnecessary intervention. Here, we present a case of multiple pulmonary masses that initially were presumed to be malignancy, leading to CT-guided biopsy, but were eventually confirmed to be thoracic splenules through 99mTc-labeled sulfur colloid scintigraphy.

Role of Complement C5 in Experimental Blunt Chest Trauma-Induced Septic Acute Lung Injury (ALI).

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.

[THE TREATMENT OF INJURED PERSONS WITH COMPLICATED PENETRATING THORACIC WOUNDINGS ON TERTIARY LEVEL OF THE MEDICAL CARE DELIVERY].

The results of examination and treatment of 36 injured persons with complicated penetrating thoracic woundings in tertiary centres were analyzed. Own experience of the pulmonary woundings surgical treatment, using application of videothoracoscopic and welding-coagulating equipment, was summarized.