Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

Blunt mechanism chest wall injury: initial patient assessment and acute care priorities.

Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.

Trends in the incidence of rib and sternal fractures: A nationwide study of the global burden of disease database, 1990-2019.

INTRODUCTION: Fractures of the ribs and sternum are associated with significant morbidity and mortality. Characterization of the injury burden across England is necessary to inform and evaluate developments in trauma care and infrastructure, however is yet to be comprehensively undertaken. Therefore, the aim of this study was to describe trends in the incidence of sternal and rib fractures across England between 1990 and 2019. MATERIALS AND METHODS: Age-standardised incidence rates (ASIRs) for rib and sternal fractures in males and females were extracted from the 2019 Global Burden of Disease (GBD) study by all causes, falls and road traffic collisions for 9 sub-regions of England. Temporal trends within the study period were analysed using Joinpoint regression analysis. RESULTS: The overall ASIRs in England in 2019 were 30.34/100,000 and 46.02/100,000 for females and males, respectively. Between 1990 and 2019, the estimated overall percentage change across England was +0.20 % among females and -7.05 % among males. A statistically significant increase in ASIR was observed in all 9 sub-regions of England among females from 2014-2019 (p<0.001). Among males, a statistically significant increase in ASIR was observed in 7 of the 9 regions from 2014-2019 (p<0.001) and in the remaining 2 regions from 2015-2019 (p<0.001). DISCUSSION: Increasing ASIRs of rib and sternal fractures were observed among females and decreasing ASIRs among males, with overall ASIRs higher among males. Developments in trauma infrastructure and associated variations in diagnostic and management strategies over the observation period likely contribute to changes in the national injury burden. The findings are suggestive of the importance of ongoing financial investment in trauma infrastructure and of clear clinical guidelines to manage an increasing national injury burden.

Study to evaluate the readability and visual appearance of online resources for blunt chest trauma: an evaluation of online resources using mixed methods.

OBJECTIVES: Blunt chest trauma (BCT) is characterised by forceful and non-penetrative impact to the chest region. Increased access to the internet has led to online healthcare resources becoming used by the public to educate themselves about medical conditions. This study aimed to determine whether online resources for BCT are at an appropriate readability level and visual appearance for the public. DESIGN: We undertook a (1) a narrative overview assessment of the website; (2) a visual assessment of the identified website material content using an adapted framework of predetermined key criteria based on the Centers for Medicare and Medicaid Services toolkit and (3) a readability assessment using five readability scores and the Flesch reading ease score using Readable software. DATA SOURCES: Using a range of key search terms, we searched Google, Bing and Yahoo websites on 9 October 2023 for online resources about BCT. RESULTS: We identified and assessed 85 websites. The median visual assessment score for the identified websites was 22, with a range of -14 to 37. The median readability score generated was 9 (14-15 years), with a range of 4.9-15.8. There was a significant association between the visual assessment and readability scores with a tendency for websites with lower readability scores having higher scores for the visual assessment (Spearman's r=-0.485; p<0.01). The median score for Flesch reading ease was 63.9 (plain English) with a range of 21.1-85.3. CONCLUSIONS: Although the readability levels and visual appearance were acceptable for the public for many websites, many of the resources had much higher readability scores than the recommended level (8-10) and visually were poor.Better use of images would improve the appearance of websites further. Less medical terminology and shorter word and sentence length would also allow the public to comprehend the contained information more easily.

Does improved patient care lead to higher treatment costs? A multicentre cost evaluation of a blunt chest injury care bundle.

BACKGROUND: Blunt chest injury is associated with significant adverse health outcomes. A chest injury care bundle (ChIP) was developed for patients with blunt chest injury presenting to the emergency department. ChIP implementation resulted in increased health service use, decreased unplanned Intensive Care Unit admissions and non-invasive ventilation use. In this paper, we report on the financial implications of implementing ChIP and quantify costs/savings. METHODS: This was a controlled pre-and post-test study with two intervention and two non-intervention sites. The primary outcome measure was the treatment cost of hospital admission. Costs are reported in Australian dollars (AUD). A generalised linear model (GLM) estimated patient episode treatment costs at ChIP intervention and non-intervention sites. Because healthcare cost data were positive-skewed, a gamma distribution and log-link function were applied. RESULTS: A total of 1705 patients were included in the cost analysis. The interaction (Phase x Treatment) was positive but insignificant (p = 0.45). The incremental cost per patient episode at ChIP intervention sites was estimated at $964 (95 % CI, -966 - 2895). The very wide confidence intervals reflect substantial differences in cost changes between individual sites Conclusions: The point estimate of the cost of the ChIP care bundle indicated an appreciable increase compared to standard care, but there is considerable variability between sites, rendering the finding statistically non-significant. The impact on short- and longer-term costs requires further quantification.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Focused and Extended Focused Assessment With Sonography for Trauma.

Timing is crucial when caring for an injured patient, and the evaluation requires a systematic, rapid, and thorough assessment to identify and treat immediate life-threatening injuries. An integral component of this assessment is the Focused Assessment with Sonography for Trauma (FAST) and the extended FAST (eFAST). These assessments allow for a rapid, noninvasive, portable, accurate, repeatable, and inexpensive means of diagnosing internal injury to the abdomen, chest, and pelvis. Understanding the basic principles of ultrasonography, having a thorough familiarity with the equipment, and being knowledgeable in anatomy allow the bedside practitioner to use this tool to rapidly assess injured patients. This article reviews the basic tenets that underpin the FAST and eFAST evaluations. Practical interventions and tips are provided to assist novice operators-all with the goal of decreasing the learning curve.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument.

STUDY OBJECTIVE: Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable. METHODS: We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries. RESULTS: One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]). CONCLUSION: In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

Value of NEXUS chest rules in assessment of traumatic chest injuries; a systematic review and a meta-analysis.

BACKGROUND: Although many studies have evaluated the diagnostic value of the National Emergency X-ray Utilization Studies (NEXUS) chest rules in assessment of traumatic chest injuries, there still is no consensus on this subject matter. Therefore, this systematic review and meta-analysis aims to review the current existing literature in order to evaluate the diagnostic value of NEXUS chest rules for assessment of traumatic chest injuries. METHOD: Databases of Medline, Embase, Scopus and Web of Science were searched until August 20th, 2022. Two independent reviewers screened the articles related to the diagnostic value of NEXUS chest radiography, NEXUS chest CT-all and NEXUS chest-Major. RESULTS: Data of 6 studies, on 23,741 patients, were included in this review. Since only one article assessed the value of NEXUS chest CT scan, the meta-analysis was performed only on NEXUS chest radiography rule. Pooled analysis on the results of 5 articles showed that the AUC of NEXUS chest radiography rule in assessment of traumatic chest injuries was 0.98 (95% CI: 0.96 to 0.99), with a sensitivity and specificity of 0.99 (95% CI: 0.98 to 0.99) and 0.32 (95% CI: 0.17 to 0.52), respectively. Positive and negative likelihood ratio of NEXUS chest radiography rule were 1.46 (95% CI: 1.12 to 1.90) and 0.04 (95% CI: 0.03 to 0.06). Overall diagnostic odds ratio was calculated to be 36.67 (95% CI: 19.17 to 70.16). CONCLUSION: Our findings indicate that NEXUS chest radiography rule is a sensitive decision rule for assessment of traumatic chest injuries, but its specificity was found to be low. However, few articles have investigated the diagnostic value of NEXUS chest rules, especially the NEXUS chest CT scan, and more studies need to be done in order to strengthen the currently provided results.

Diagnostic Inaccuracies Using Extended Focused Assessment With Sonography in Trauma for Traumatic Pneumothorax.

BACKGROUND: Traumatic pneumothorax (PTX) can be deadly, and rapid diagnosis is vital. Ultrasound (US) is rapidly gaining acceptance as an accurate bedside diagnostic tool. While making the diagnosis is important, not all PTX require tube thoracostomy. Our goal was to evaluate the predictive ability of ultrasound in identifying clinically significant PTX. METHODS: Over 13 months, data was collected on patients undergoing evaluation for trauma. Patients were included if they underwent US, radiograph chest X-ray (CXR), and computed tomography of the chest. Predictive ability of ultrasound was evaluated in identifying clinically significant PTX. RESULTS: Ninety-four patients received evaluation by all 3 modalities. Of these, 32% were diagnosed with PTX. Sixteen patients (17%) had a clinically significant PTX. Chest X-ray and US both had a sensitivity of 75%; however, US had more than twice as many false positives, resulting in a much lower positive predictive value (63% vs 80%). CONCLUSIONS: While US can reliably rule out PTX, it may be overly sensitive diagnosing clinically significant PTX. Ultrasound alone should not be used in determining the need for tube thoracostomy as many patients will not require acute intervention.

The evolution of a chest wall injury and reconstruction clinic during a pandemic.

BACKGROUND: In 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need and evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an acute care surgery/general surgery (ACS/GS) clinic to a CWIRC. METHODS: We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from January 1, 2017, to November 30, 2021. Outpatient and operative work relative value unit (wRVU) production as well as payer mix was compared as the primary outcome. RESULTS: Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVUs in 2017 to 295 wRVUs in 2021. The CWIRC patient visits increased from 4% to 70%. In addition, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017-253 vs. 2021-591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVUs. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared with ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%). CONCLUSION: The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVUs per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The cost of treatments for retained traumatic hemothorax: A decision analysis.

INTRODUCTION: Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies. METHODS: A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy. RESULTS: In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900. CONCLUSION: Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Traumatic Impact Assessment of CPR Load on a Human Ribcage.

Chest compression is a parameter of injury criteria assessment for human beings. Additionally, it is used to find the external compression response as a result of vehicle crashes, falls, or sporting impacts. This behavioral feature is described by many deterministic models related to specific experimental tests, hindering distinct scenarios. The present study evaluates the energy absorbed as a function of rib compression. The proposed model was obtained from three different computed tomography (CT) studies. The anthropometric values are interpolated to obtain a parametric curve for a human rib's average size. The computed results are compared against an STL-DICOM® file used to obtain a virtual reconstruction of one rib. A numerical model of the behavior of the thorax displacement expressed injury in the human rib model's stiffness. The proposed model is used to determine the correlation of the input payload versus the numerical stiffness value. The outcome is confirmed by numerical analyses applied to a virtual human rib reconstruction.

A new screening model for quantitative risk assessment of blunt thoracic aortic injury.

PURPOSE: Early identification of blunt thoracic aortic injury is vital for preventing subsequent aortic rupture. However, risk factors for blunt thoracic aortic injury remain unclear, and a prediction rule remains to be established. We developed and internally validated a new nomogram-based screening model that allows clinicians to quantify blunt thoracic aortic injury risk. METHODS: Adult patients (age ≥ 18 years) with blunt injury were selected from a nationwide Japanese database (January 2004-May 2019). Patients were randomly divided into training and test cohorts. A new nomogram-based blunt thoracic aortic injury-screening model was constructed using multivariate logistic regression analysis to quantify the association of potential predictive factors with blunt thoracic aortic injury in the training cohort. RESULTS: Overall, 305,141 patients (training cohort, n = 152,570; test cohort, n = 152,571) were eligible for analysis. Median patient age was 65 years, and 60.9% were men. Multivariate analysis in the training cohort revealed that 13 factors (positive association: age ≥ 55 years, male sex, high-energy impact, hypotension on hospital arrival, Glasgow Coma Scale score < 9 on hospital arrival, diaphragmatic injuries, hepatic injuries, pulmonary injuries, cardiac injuries, renal injuries, sternum fractures, multiple rib fractures, and pelvic fractures) were significantly associated with blunt thoracic aortic injury and included in the screening model. In the test cohort, the new screening model had an area under the curve of 0.87. CONCLUSIONS: Our novel nomogram-based screening model aids in the quantitative assessment of blunt thoracic aortic injury risk. This model may improve tailored decision-making for each patient.

Socioeconomic and Psychosocial Predictors of Magnetic Resonance Imaging After Cervical and Thoracic Spine Trauma in the United States.

OBJECTIVE: Socioeconomic factors are known to influence outcomes after spinal trauma, but it is unclear how these factors affect health care utilization in acute care settings. We aimed to elucidate if sociodemographic and psychosocial factors are associated with obtaining magnetic resonance imaging (MRI), a costly imaging modality, after cervical or thoracic spine fracture. METHODS: Data from the 2012-2016 American College of Surgeons National Trauma Data Bank were used. We assessed the relationship between receipt of MRI and patient-level sociodemographic and psychosocial factors as well as hospital characteristics while correcting for injury-specific characteristics. Multiple logistic regression was performed to assess for associations between these variables and MRI after spine trauma. RESULTS: A total of 213,071 patients met the inclusion criteria, of whom 13.0% had an MRI (n = 27,757). After adjusting for confounders in multivariate regression, patients had increased odds of MRI if they were Hispanic (odds ratio [OR], 1.09; P = 0.001) or black (OR, 1.14; P < 0.001) or were diagnosed with major psychiatric disorder (OR, 1.06; P = 0.009), alcohol use disorder (OR, 1.05; P < 0.001), or substance use disorder (OR, 1.10; P < 0.001). Patients with Medicare (OR, 0.88; P < 0.001) or Medicaid (OR, 0.94; P < 0.011) were less likely to have an MRI than were those with private insurance, whereas patients treated in the Northeast (OR, 1.48; P < 0.001) or at for-profit hospitals (OR, 1.12; P < 0.001) were more likely. CONCLUSIONS: After adjusting for injury severity and spinal cord injury diagnosis, psychosocial comorbidities and for-profit hospital status were associated with higher odds of MRI, whereas public insurance was associated with lower odds. Results highlight potential biases in the provision of MRI as a costly imaging modality.

Comparing diagnostic findings and cost of whole body computed tomography to traditional diagnostic imaging in polytrauma patients.

OBJECTIVE: To compare the diagnostic utility of traditional diagnostic tests (ie, radiographs and focused assessment using sonography for trauma [FAST] scans) to whole-body computed tomography (WBCT) for characterizing injuries in polytrauma patients. A secondary objective was to compare costs of traditional diagnostic tests to WBCT. DESIGN: Prospective, observational study. SETTING: Private, level 1 veterinary trauma center. ANIMALS: Convenience sample of 21 client-owned cats and dogs presenting with polytrauma. INTERVENTIONS: Abdominal and thoracic FAST were performed by the primary clinician, if indicated. Radiographs were performed on areas concerning for trauma at the primary clinician's discretion. A WBCT was performed on each patient within 24 h of presentation and was blindly interpreted by a board-certified radiologist. Patients were only placed under anesthesia if further procedures were planned. IV contrast administration was employed at the discretion of the primary clinician and radiologist. MEASUREMENTS AND MAIN RESULTS: Twenty-one patients (14 dogs and 7 cats) were enrolled. Sources of trauma included blunt force (80%), penetrating wounds (10%), and unknown sources (10%). Twelve injuries were missed on traditional diagnostics tests. Injuries missed on traditional diagnostic workup included pneumothorax, pneumomediastinum, pulmonary contusions, pleural effusion, traumatic bulla, peritoneal effusion, and an appendicular skeleton fracture. A distal metacarpal fracture was missed on WBCT. Traditional diagnostic tests misdiagnosed a diaphragmatic hernia and a ruptured urinary bladder, whereas WBCT was able to rule out these injuries. There were no adverse outcomes associated with missed injuries. The median cost of traditional diagnostic tests was significantly less than the cost of WBCT (P < 0.001). CONCLUSIONS: Although cost is higher, WBCT is a single test that can provide more comprehensive information and may help decrease the risk of missed injuries compared to traditional diagnostic tests. WBCT may be considered as a first-line diagnostic in severely traumatized patients.

Prolonged Prehospital Time Is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP Study): A Retrospective Analysis of the United States National Trauma Data Bank.

BACKGROUND: Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown. RESEARCH QUESTION: Is prolonged prehospital time an independent risk factor for pneumonia? STUDY DESIGN AND METHODS: We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016. RESULTS: Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P < .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (P < .001, 4.3% mortality without pneumonia vs 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns. INTERPRETATION: Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Motorcyclist injuries: Analysis of German in-depth crash data to identify priorities for injury assessment and prevention.

Globally there are more than 350,000 PTW fatalities each year. Safety concepts to protect Powered Two-Wheeler (PTW) riders exist and are being developed further, but they need appropriate procedures and test tools (Anthropometric Test Devices (ATDs) for physical testing and Human Body Models (HBMs) for virtual testing) to direct and promote those developments. To aid further development of the tools, we aim to rank the frequency of specific injuries arising from the prevalent impact types, discuss how current ATDs and HBMs are equipped to assess these injuries, and suggest what further development should be prioritized. We analyzed a sample of injured riders from the German In-depth Accident Study (GIDAS) according to the Abbreviated Injury Scale (AIS) 2015 classification, using severity thresholds of at-least-moderate (AIS2+) and at-least-serious (AIS3+). PTW rider injuries were ranked by frequency for all crashes and also for sub-samples of specific impact types (impact with passenger cars, ground, and roadside furniture). The most frequent AIS3+ injuries were: femur fracture (17%), rib cage fracture (13%), lung injury (9%), tibia fracture (7%), and cerebrum injury (7%). In all impacts together and as for impacts with the road surface, injuries to the thorax were most frequent. In impacts with cars and road furniture, thorax injuries were also frequent, but outranked by lower extremity injuries. Considering both AIS2+ and AIS3+ injuries, the priorities for PTW rider safety interventions are: fracture of the rib cage, femur fracture, tibia fracture, radius fracture, cerebrum injury, and cerebral concussion. The ATD currently used most frequently, the Hybrid III, is unlikely to provide adequate rib fracture injury assessments, but HBMs are promising in this area. Rib injury assessment may also reasonably predict other injuries that were correlated or in proximity to rib fractures: clavicle, lung, and upper abdomen organ injury. Lower extremity, upper extremity, and head injuries are likely addressable to some extent with current ATDs while HBMs hold the promise of more detailed and mechanism-specific injury assessments. Both ATDs and HBMs need more validation for use in the PTW environment.

Standardized post-resuscitation damage assessment of two mechanical chest compression devices: a prospective randomized large animal trial.

BACKGROUND: Mechanical chest compression devices are accepted alternatives for cardiopulmonary resuscitation (CPR) under specific circumstances. Current devices lack prospective and comparative data on their specific cardiovascular effects and potential for severe thoracic injuries. OBJECTIVES: To compare CPR effectiveness and thoracic injuries of two mechanical chest compression devices in pigs. STUDY DESIGN: Prospective randomised trial. ANIMALS: Eighteen male German landrace pigs. METHODS: Ventricular fibrillation was induced in anaesthetised and instrumented pigs and the animals were randomised into two intervention groups. Mechanical CPR was initiated by means of LUCAS™ 2 (mCCD1) or Corpuls™ cpr (mCCD2) device. Advanced life support was applied for a maximum of 10 cycles and animals achieving ROSC were monitored for 8 h. Ventilation/perfusion measurements were performed and blood gas analyses were taken. Thoracic injuries were assessed via a standardised damage score. RESULTS: Five animals of the mCCD1 group and one animal of the mCCD2 group achieved ROSC (p = 0.048). Only the mCCD1 animals survived until the end of the monitoring period (p < 0.01). MCCD1 animals showed less pulmonary shunt (p = 0.025) and higher normal V/Q (p = 0.017) during CPR. MCCD2 animals showed significantly more severe thoracic injuries (p = 0.046). CONCLUSION: The LUCAS 2 device shows superior resuscitation outcomes and less thoracic injuries compared to Corpuls cpr when used for experimental CPR in juvenile pigs. Researchers should be aware that different mCCDs for experimental studies may significantly influence the respective outcome of resuscitation studies and affect comparability of different trials. Controlled human and animal CPR studies and a standardised post-resuscitation injury evaluation could help to confirm potential hazards. TRIAL REGISTRATION: Trial approval number: G16-1-042-E4.