Evaluating the Shock Index, Revised Assessment of Bleeding and Transfusion (RABT), Assessment of Blood Consumption (ABC) and novel PTTrauma score to predict critical transfusion threshold (CAT) in penetrating thoracic trauma.

The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.

Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): a study protocol for a randomised non-inferiority trial.

INTRODUCTION: Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician's discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces. METHODS AND ANALYSIS: The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months. ETHICS AND DISSEMINATION: This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN35574247.

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.

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.

Is there a role for REBOA? A system assessment.

INTRODUCTION: To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS: Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared. RESULTS: Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm. DISCUSSION: The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region. LEVEL OF EVIDENCE: IV.

Bedside Ultrasound Assessment of Lung Reaeration in Patients With Blunt Thoracic Injury Receiving High-Flow Nasal Cannula Oxygen Therapy: A Retrospective Study.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy has been shown to reduce the need for mechanical ventilation and decrease the duration of hospital and intensive care unit (ICU) stays for patients with a severely compromised respiratory system. This study aims to observe the evolution of lung aeration via lung ultrasound score (LUS) in a chest-injured population who had been treated with HFNC oxygen therapy, and to assess the benefit of the HFNC oxygen therapy in trauma patients. METHODS: A retrospective study examined trauma patients with moderate to severe thoracic injuries who were admitted to the ICU at a tertiary hospital between October 2015 and March 2017. The decision to initiate HFNC oxygen therapy was made at the discretion of the trauma surgeon and respiratory therapist when supplemental oxygen delivery was required. All of the patients were assessed by transthoracic lung ultrasound every day after being admitted into the ICU. We retrospectively analyzed 3 time points for this study: the initial emergency intensive care units presentation within 12 hours (T1), 24 to 48 hours after the treatment (T2), and 72 to 96 hours after the treatment (T3). Transthoracic lung ultrasound was performed by an experienced investigator with level 3 certification using a Mindray M9 echograph and a 2- to 4-MHz round-tipped probe. Primary outcomes were the need for intubation after HFNC oxygen therapy for respiratory failure during the treatment within 72 hours, the length of ICU stay, and mortality of 28 days. RESULTS: During the study period, 50 patients with blunt chest trauma were admitted to the study; 18 patients received HFNC therapy and 32 received conventional oxygen therapy (COT); there was no significant difference in the baseline clinical characteristics between the 2 groups. The length of ICU stay and intubation rate for respiratory failure within 72 hours were significantly different between the 2 groups (P < .05), but there was no difference in the 28-day mortality. The LUS of the COT group was not significantly different from T1 to T2 or from T2 to T3 (P > .05). However, the LUS decreased significantly-by 25% from T1 to T2 (P < .05) and by 31% from T1 to T3 (P < .05) in the HFNC therapy group. The LUS of the patients intubated for respiratory failure within 72 hours, in the COT group increased from T1 (17 ± 3) to T3 (21 ± 3), and the LUS (21 ± 3) was much higher than the patients who were not intubated (11 ± 3) at T3; the LUS of the HFNC group was all above 15, which was not significantly different from T1 to T2 or from T2 to T3 (P > .05). CONCLUSIONS: High-flow nasal cannula oxygen therapy may be considered as an initial respiratory therapy for trauma patients with blunt chest injury. High-flow nasal cannula therapy could improve lung aeration as noted by the transthoracic lung ultrasound assessment, and LUS may help the attending physicians identify the usefulness of HFNC therapy and decide whether to continue the use of HFNC therapy or intubate the patient.

Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol.

INTRODUCTION: A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS: In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION: The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER: NTR6833.

A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial.

OBJECTIVE: A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED. DESIGN: Stepped wedge feasibility trial. SETTING: Four EDs in England and Wales. PARTICIPANTS: Adult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries. INTERVENTION: A prognostic model (the STUMBL score) to guide clinical decision-making. OUTCOME MEASURES: Primary: participant recruitment rate and clinicians' use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation. RESULTS: Quantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible. DISCUSSION: We have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial. TRIAL REGISTRATION NUMBER: ISRCTN95571506; Post-results.

Socioeconomic disparities in the thoracic trauma population.

BACKGROUND: Health-care disparities based on socioeconomic status have been well documented in the trauma literature; however, there is a paucity of data on how these factors affect outcomes in patients experiencing severe thoracic trauma. This study aims to identify the effect of insurance status and race on patient mortality and disposition after thoracic trauma. METHODS: The National Trauma Data Bank was queried from 2007 to 2012 for patients with sternal fractures, rib fractures, and flailed chest. Demographics data were examined for the cohort based on insurance status. Univariate and multivariate logistic regression models were used, controlling for patient comorbidities, age, injury severity score, and associated injuries, to determine the impact of race and insurance status on length of stay, mortality, and discharge disposition. RESULTS: A total of 152,655 thoracic traumas were included in our analysis. As compared to privately insured patients, uninsured patients with thoracic trauma were 1.9 times more likely to die (odds ratio [OR]: 1.91, confidence interval [CI]: 1.76-2.09) and 4.6 times more likely to leave against medical advice (OR: 4.61, CI: 3.14-6.79). When compared to Caucasians, Hispanics had slightly higher in-hospital mortality (OR: 1.14, CI: 1.02-1.27), but there was no survival difference seen in black patients (OR: 0.95, CI: 0.86-1.05). CONCLUSIONS: Insurance status appears to have a more significant effect on thoracic trauma patient outcomes than race, but substantial socioeconomic disparities were seen in this patient population. Further studies are needed to show reproducibility of our findings and to investigate the impact of universal health care and expansion of insurance availability on thoracic trauma outcomes. LEVEL OF EVIDENCE: Level 3, economic/decision.

Protocol for a multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL trial.

INTRODUCTION: A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). A definitive randomised controlled trial (impact trial) is required to assess the clinical and cost effectiveness of the new model before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design. METHODS/ANALYSIS: This feasibility trial is designed to test the methods of a multicentre, cluster-randomised (stepped- wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a 5-month period; in the initial period acting as the controls (normal care), and in the second period acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a 6-week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory). Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed. ETHICS AND DISSEMINATION: Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Patient recruitment will commence in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings. TRIAL REGISTRATION NUMBER: ISRCTN95571506; Pre-results.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Cost prediction following traumatic brain injury: model development and validation.

OBJECTIVE: The ability to predict costs following a traumatic brain injury (TBI) would assist in planning treatment and support services by healthcare providers, insurers and other agencies. The objective of the current study was to develop predictive models of hospital, medical, paramedical, and long-term care (LTC) costs for the first 10 years following a TBI. METHODS: The sample comprised 798 participants with TBI, the majority of whom were male and aged between 15 and 34 at time of injury. Costing information was obtained for hospital, medical, paramedical, and LTC costs up to 10 years postinjury. Demographic and injury-severity variables were collected at the time of admission to the rehabilitation hospital. RESULTS: Duration of PTA was the most important single predictor for each cost type. The final models predicted 44% of hospital costs, 26% of medical costs, 23% of paramedical costs, and 34% of LTC costs. Greater costs were incurred, depending on cost type, for individuals with longer PTA duration, obtaining a limb or chest injury, a lower GCS score, older age at injury, not being married or defacto prior to injury, living in metropolitan areas, and those reporting premorbid excessive or problem alcohol use. CONCLUSIONS: This study has provided a comprehensive analysis of factors predicting various types of costs following TBI, with the combination of injury-related and demographic variables predicting 23-44% of costs. PTA duration was the strongest predictor across all cost categories. These factors may be used for the planning and case management of individuals following TBI.

What is the yield of routine chest radiography following tube thoracostomy for trauma?

INTRODUCTION: Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown. MATERIALS AND METHODS: We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS® recommendations. RESULTS: A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre-insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR. CONCLUSIONS: Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS® guidelines in these specific environments.

A simple assessment of haemothoraces thickness predicts abundant transfusion: a series of 525 blunt trauma patients.

BACKGROUND: The goal of this study was to evaluate the performance of haemothorax quantification to predict an abundant transfusion in blunt thoracic trauma patients. METHODS: This study included all severe trauma patients admitted into our trauma centre from January 2005 to January 2010, who presented a blunt thoracic trauma (thoracic AIS ≥1) and had a CT scan within the first hour following admission. For each haemothorax, thickness of dominant side and the cumulated thicknesses of both sides (Dominant-t, Cumulated-t), as well as lengths (Dominant-l, Cumulated-l) and the calculated volumes (Dominant-v, Cumulated-v provided by a previously validated formula) were retrospectively measured by CT scan. A multiple logistic regression was performed to define the independent risk factors for an abundant transfusion (≥5 packed red blood cells in the first 24h). Finally, ROC curves have been drawn on an isolated thoracic trauma subgroup to predict abundant transfusion. The more specific cut-offs were extracted from this analysis. RESULTS: From the 525 blunt thoracic trauma patients (75% males, mean age 38.2 (SD18.7) years, mean ISS 22.5 (SD16.4)), 31% received an abundant transfusion. In multivariable analysis, Cumulated-t was significantly associated with an abundant transfusion (OR 1.3 [95% CI 1.1-1.4], P=0.002). In isolated thoracic trauma subgroup (n=251), the global abilities of different CT measurements to predict abundant transfusion were significantly comparable (AUCs 0.69-0.70). The more specific cut-offs were established at 28mm for Cumulated-t (specificity 92%, positive predictive value 47%) and at 24mm for Dominant-t (specificity 92%; positive predictive value 43%). CONCLUSION: The haemothorax quantification upon admission may help to predict transfusion needs. Cumulated-t was found independent risk factor for abundant transfusion in a large population of severe trauma patients. Beyond a Cumulated-t of 28mm or a Dominant-t of 24mm, abundant transfusion will be very frequently necessary. LEVEL OF EVIDENCE: Retrospective review, level III.

A new aortic injury score predicts early rupture more accurately than clinical assessment.

OBJECTIVE: The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS: Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS: The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS: This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.

Ultrasonido torácico extendido en trauma (EFAST) / Thoracic ultrasound. extended focus assessment with sonography in trauma (EFAST)

Dentro del abordaje diagnóstico del trauma torácico se cuenta con múltiples auxiliares diagnósticos, entre ellos el ultrasonido FAST extendido a tórax (EFAST). Para la detección de hemo o neumotórax, la radiografía de tórax ha demostrado una sensibilidad de 69% y especificidad de 76%, con la tomografía la sensibilidad y especificidad se acercan al 100%. El EFAST ha demostrado una sensibilidad del 92-100%, aun realizado por médicos no radiólogos Objetvo: evaluar la sensibilidad y especifcidad del ultrasonido torácico extendido (EFAST) dentro de la práctca en la atención de emergencia en elservicio de emergencia en el Hospital Roosevelt Método: Se realizó un estudio descriptvo, tansversal de pacientes que ingresaron con trauma cerrado y penetrante en tórax a quienes se les realizóEFAST, radiografa de tórax y tomografa torácica Resultados: De 16 pacientes, 13 (81.25%) fueron hombres y tres (18.75%) mujeres. 11 (68.75%) con trauma contuso y 5 (31.25%) con trauma penetrante.El grupo de edad más afectado fue el comprendido entre los 18 a 45 años. De los 16 estudios realizados, nueve (56.25%) fueron califcados comopositvos para neumotórax, observándose el signo de la estratosfera en los nueve casos (100%); el resultado fue corroborado con radiografa de tórax ytomografa. Un paciente presentó alteraciones tomográfcas compatbles con hemoneumotórax que no fueron detectadas por ecografa; procediendoa colocación de tubo de toracostomía cerrada de manera inmediata. Los 7 pacientes restantes no tuvieron evidencia de lesión torácica por EFAST ni enlos estudios complementarios (radiografa, tomografa o EFAST de control) ni durante el seguimiento clínico. Conclusión: Durante la experiencia inicial el EFAST demostró ser sufcientemente sensible y específco para detectar neumotórax.

Background: The diagnosis of hemothorax or pneumothorax is established with chest radiography (sensitvity 69%, specifcity 76%) or computed tomography(sensitvity and specifcity near 100%). Studies have shown that EFAST has 92-100 % sensitvity even for non-radiologists. The aim of this studywas to determine sensitvity and specifcity of EFAST in the emergency department of Roosevelt Hospital.Methods: All patents admited from January to July 2015, with blunt or penetratng chest trauma were included in this study. They underwent EFAST,chest radiography and thoracic computed tomography.Results: Sixteen patents were analyzed, 13 (81.25%) were men, 11 (68.75%) presented blunt trauma and 5 (31.25%) penetratng trauma. The age groupwas from 18 to 45 years old. Of the 16 studies performed, 9 (56.25%) were classifed as positve for pneumothorax by EFAST, stratosphere positve signwas present in all of them; results were corroborated with chest radiography and tomography. One patent presented tomographic signs of hemo-pneumothoraxthat was not detected by ultrasound. The remaining 7 patents did not have evidence of thoracic injury with EFAST, chest radiography, thoracictomography or during clinical follow-up.Conclusions: During inital experience, EFAST demonstrates to be sensitve and specifc enough to detect pneumothorax.

Assessment of internal mammary artery injury after blunt chest trauma: a literature review.

The occurrence, bleeding, and treatment of internal mammary artery (IMA) injury after blunt chest trauma have not been well described in the literature. We reviewed articles published from July 1977 to February 2014 describing IMA injury after blunt chest trauma in 49 patients. There was a predominant incidence in males and on the left side. Blunt trauma to the IMA can cause anterior mediastinal hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and extra-pleural hematoma. Of the 49 patients studied, 20 underwent embolization, 22 underwent surgical operation, 4 were managed by clinical observation, and 3 had undescribed treatment. Different parts and extents of IMA injury, adjacent vein injury, as well as the integrity of the pleura determined differences in bleeding modality. Prompt diagnosis, complete hemostasis, aggressive resuscitation, and multidisciplinary teams are recommended for patients with IMA injury.

Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial.

BACKGROUND: Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey. However, this is not evidence-based as there has been no randomized trial. METHODS: In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST. The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment). Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant). As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform. CONCLUSION: This study shows that DPL is better than FAST.

Evolution of the incidence, management, and mortality of blunt thoracic aortic injury: a population-based analysis.

BACKGROUND: In the last decade, CT angiography has become the dominant diagnostic modality for blunt aortic injury and endovascular repair has become the leading aortic repair strategy. The impact of these shifts on incidence, aortic repair rate, and mortality remains poorly characterized. Our objective was to perform a population-based analysis of secular trends in the incidence, management, and in-hospital mortality of blunt thoracic aortic injury. STUDY DESIGN: From the population-based Canadian National Trauma Registry, we identified a cohort of all adults hospitalized between April 2002 and March 2010 with a diagnosis of thoracic aortic injury after blunt trauma. Trends over time in the incidence of hospitalization, frequency and type of aortic repair, as well as risk-adjusted in-hospital mortality, were evaluated. RESULTS: A total of 487 incident cases of blunt thoracic aortic injury were identified. During the study period, the incidence of hospitalization for blunt thoracic aortic injury remained stable (trend p = 0.16). Although the proportion of repairs undertaken via an endovascular approach increased (11% to 78% of repairs; trend p < 0.001), the frequency of any repair (endovascular or open) declined (55% to 36%; trend p = 0.003). Across all patients, when controlling for age, sex, mechanism of injury, and presence of severe extrathoracic injuries, mortality remained unchanged during the study period (odds ratio = 0.92 per 1 year; 95% CI, 0.82-1.03). However, in patients managed nonoperatively, risk-adjusted mortality decreased over time (odds ratio = 0.85 per 1 year; 95% CI, 0.80-0.98). CONCLUSIONS: The increasing frequency of patients managed nonoperatively and decreasing risk-adjusted mortality in these patients suggests that defining the evolving role of nonoperative management should be a major focus of research in the endovascular era.