Penetrating Thoracic Trauma Patients with Gross Physiological Derangement: A Responsibility for the General Surgeon in the Absence of Trauma or Cardiothoracic Surgeon?

BACKGROUND: Penetrating trauma is becoming increasingly common in parts of the world where previously it was rare. At the same time, general surgeons and surgical trainees are becoming more specialized, and less comfortable operating within areas beyond their zone of specialization. OBJECTIVE: The purpose of this manuscript is to assess the technical difficulties encountered in operating on patients who have sustained penetrating trauma, and to prove to general surgeons that the technical skills and techniques required are no different to those required for abdominal surgery, and do not require additional dexterity. METHODS: This prospective study was conducted in an Academic Trauma unit over a 3-year period. All patients who were operated upon for penetrating thoracic trauma were included in the study. The pre-operative management, techniques of surgical repair and the outcome were assessed. RESULTS: One hundred and forty-five patients were included in the study over a 3-year period. There were 97 patients with stab wounds, 47 with gunshot wounds and 1 patient with an injury from an angle grinder. Mortality was six times greater in those patients with gunshot wounds, than those with stab wounds. Several patients had multiple thoracic organ injuries. There were 57 patients who were operated upon for thoracic vessel injury. There was a 3.5 % mortality overall. Eighty-eight patients sustained pulmonary injury with a 7 % mortality, and they were managed mainly by simply repair, tractotomy or stapled partial non-anatomical lobectomy. Of the 39 patients with cardiac trauma, there was 17 % mortality, and all cases were managed by simple repair. There were 5 patients with an oesophageal injury of whom 3 died (mortality of 60 %). Twenty-four patients had thoraco-abdominal injuries with 30 % mortality. CONCLUSION: Most of the injuries in the chest can be managed by simple procedures to control life-threatening bleeding. The techniques required are similar to those taught to and are practiced comfortably by general surgeons used to work in the abdominal cavity. We encourage the general surgeon who receives a grossly unstable patient with penetrating thoracic trauma to operate, instead of adding risk to the patient's physiology by a transfer to cardio-thoracic or dedicated trauma units.

"Mending A Broken Heart!" (a few technical tips on repairing penetrating trauma to the heart).

During the history operative repair of cardiac injuries was considered to be unmanageable and the first successful cardiomiorraphy was performed just around a century ago. Tamponade, more frequently than exsanguination are cause of death in penetrating cardiac trauma. This is a usualy lethal injury and those surviving to hospital have an overall mortality approaching 80%. The penetrating injury require some basic steps, not special operative dexterity. We present the technical management of this injury, certain danger points and pitfalls. Options for surgical exposure, technical details of suturing cardiac injuries, and exceptional conditions such as injury near the coronary artery are discussed in detail. Outcome data and future directions in managing this injury are also examined.

Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis.

INTRODUCTION: The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains. AIM OF THE STUDY: To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician. METHODS: A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies. RESULTS: This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries. CONCLUSION: Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

Technique of Cross-Clamping of Descending Thoracic Aorta During Emergency Department Thoracotomy.

Cross-clamping of the descending thoracic aorta is one of the operative maneuvers, that can be necessitated in an Emergency Department Thoracotomy and it is important for the Emergency Department medical staff to theoretically familiarize itself with its technique before need arises.

Tension pneumopericardium: case report.

Pneumopericardium is defined as the presence of air within the pericardial space. It is an uncommon complication of blunt or penetrating chest trauma and may also occur iatrogenically. 'Simple' pneumopericardium produces no discernible circulatory compromise; however, simple pneumopericardium may progress rapidly to produce cardiovascular compromise or circulatory collapse, when it is termed 'tension' pneumopericardium. Tension pneumopericardium requires emergent drainage of the pericardial sac. Failure to achieve rapid effective drainage may result in cardiac arrest. Drainage of the pericardial sac may be achieved by either percutaneous or open drainage technique. Formation of a sub-xiphoid pericardial window has been advocated as a rapid and effective means of achieving open drainage. This may be carried out at the bedside with minimal equipment, and the authors advocate this technique as the preferred option for achieving drainage. This case demonstrates the rapid and dramatic deterioration to cardiac arrest of a multiply injured trauma patient with radiologically confirmed pneumopericardium. The effectiveness of open drainage via a sub-xiphoid pericardial window at the bedside with resultant return of spontaneous circulation is also shown. In addition, the pathogenesis and natural history of this uncommon condition are reviewed and the options for management are discussed.

Gunshot wounds to the head in civilian practice.

Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during 6 1/2 years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale. Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58 per cent. The mortality for patients with an initial Glasgow Coma Scale score of < or = 8 was 81 per cent versus 14 per cent for those with initial Glasgow Coma Scale score > 8 (P < or = 0.0001). Fifty per cent had pupillary abnormalities on arrival at the Emergency Department. Mortality in this group was 78 per cent versus 53 per cent in those with normal pupillary reflexes (P = 0.06). Elevated plasma lactate was associated with nonsurvival. Thirteen per cent of survivors were assessed as able to live independently after their injury. Civilian gunshot injury to the head is related to high mortality. Indicators of outcome are the admission Glasgow Coma Scale score, pupillary abnormality, metabolic acidosis, and CT pattern of severe injury. The majority of deaths occur at an early stage. Among survivors the functional outcome can be acceptable.

Pitfalls in penetrating thoracic trauma (lessons we learned the hard way...).

The majority of patients with penetrating thoracic trauma are managed non-operatively. Those requiring surgery usually go to theater with physiological instability. The critical condition of these patients coupled with the rarity of penetrating thoracic trauma in most European countries makes their surgical management challenging for the occasional trauma surgeon, who is usually trained as a general surgeon. Most general surgeons have a general knowledge of basic cardiothoracic operative surgery, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide him with enough armamentaria to tackle the difficult case. In this anatomical region, their operative dexterity and knowledge cannot be compared to that of their cardiothoracic colleagues, something that is taken for granted in their cardiothoracic trauma textbooks. Techniques that are considered basic and easy by the cardiothoracic surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and the pitfalls that will be encountered in cardiothoracic trauma surgery will help them to avoid intraoperative errors and improve patient outcome. The purpose of this manuscript is to highlight the commonly encountered pitfalls by trauma surgeons operating on penetrating trauma to the chest.

High rates of HIV in surgical patients in Soweto, South Africa: impact on resource utilisation and recommendations for HIV testing.

Interactions between HIV and surgical diseases are relatively poorly described in high HIV prevalence settings. We report HIV prevalence and its associations in a prospective study of adults admitted to surgical units in Soweto, South Africa. Voluntary counselling and testing (VCT) for HIV was offered to surgical inpatients. Research nurses interviewed participants at enrolment and doctors reviewed records after discharge. In HIV-infected participants, CD4 counts and viral loads were ascertained. Of 1000 participants, 537 consented to VCT, of whom 176 (32.8%, 95% CI 28.8-36.9%) tested HIV positive. A history of tuberculosis (adjusted odds ratio (AOR) 3.0, 95% CI 1.5-6.2) or sexually transmitted infection (AOR 2.7, 95% CI 1.8-4.2) was associated with HIV infection. Diagnoses of cutaneous abscesses (OR 3.4, 95% CI 1.4-8.1) and anorectal sepsis (OR 3.1, 95% CI 1.1-9.0) were associated with HIV and indicated advanced disease. There were no differences in rates of operative procedures, wound sepsis, investigations or length of stay by HIV status. Hospital-acquired pneumonia was more common in HIV-infected participants (P=0.028). In conclusion, in this high HIV prevalence setting, resource utilisation is similar between HIV-infected and uninfected patients in surgical wards where high rates of HIV in young adults support routine HIV testing. WHO clinical staging of HIV should include anal sepsis as an indicator of advanced HIV disease.

Ballistic arterial trauma to the lower extremity: recent South African experience.

The aim of this study was to determine the current outcome of gunshots to the arteries of the lower extremity. The authors conducted a retrospective analysis of 104 patients with gunshots to the femoral (n=71) and popliteal (n=33) artery. One hundred four patients presented over the 60-month period. Ninety-six (92%) were male and eight of 104 female. Ninety-nine were gunshot injuries, five from shotguns. Nine patients had injury to the common femoral artery, 62 patients had injury to the superficial femoral artery, and 33 had popliteal artery injury. One patient died in the emergency room and another died in the postoperative period, giving an overall in-hospital mortality of two of 104 (1.9%). Forty-three of 70 femoral reconstructions had completion angiograms compared with 20 of 32 popliteal artery reconstructions (P=1). Nineteen of 63 (30%) of the completion angiograms prompted revision of the reconstruction. Of the 63 patients who had completion angiograms, two of 63 (3%) required amputation. Seven of 39 (18%) patients who did not have completion angiograms required amputation (P = 0.025). Including the primary amputation, there were 10 amputations in the 103 patients (9.7%) who survived to undergo operation. Ballistic arterial trauma of the lower limb leads to significant disability. Completion arteriography leads to revision of the reconstruction in nearly one-third of instances and significantly reduces amputation rate.

Emergency thoracic surgery for penetrating, non-mediastinal trauma.

BACKGROUND: Penetrating thoracic injury is commonly found in South Africa. A review of our recent experience was undertaken to assess the effectiveness of our protocols for this type of injury. METHODS: A retrospective study of 61 consecutive patients with penetrating, non-mediastinal trauma to the chest was conducted over 32 months at a single trauma unit. Patient details, mechanism of injury, operative procedure and in-hospital mortality and morbidity rates were recorded. RESULTS: Two thousand and nineteen patients presented with penetrating chest injury of which 61 patients (3%) underwent thoracic surgery for non-mediastinal injury. Twenty-six patients had stab wounds and 35 had gunshot wounds. Overall mortality was 17/61 (28%). Gunshot wounds were more likely to result in death than stab wounds (relative risk = 11.9; 95% confidence interval 1.7-84.0) and thoracoabdominal injury resulted in death more commonly than chest injury (relative risk = 4.8; 95% confidence interval 2.2-10.3) resulted in death. CONCLUSION: Penetrating chest injury is common and most patients can be managed without formal thoracic surgical intervention. However, the patients who do merit surgical intervention have a relatively high mortality and a rapid and practised operative approach is required to achieve acceptable results.

Penetrating vascular trauma in Johannesburg, South Africa.

An awareness that time crucially affects outcome underpins the principles of management of vascular injury. Patients with hard signs of vascular injury should undergo urgent exploration. Soft signs mandate investigation, and arteriography is still the standard of care. Noninvasive vascular imaging may prove its worth in the future. All patients with penetrating arterial injury should receive broad-spectrum antibiotic prophylaxis. Early repair of carotid artery injury provides the best likelihood of a neurologically intact survivor. There is a definite and emerging role of endovascular therapy both for difficult access injuries and for the later complications of vascular injury, such as false aneurysm and arteriovenous fistulas. The experimental and clinical evidence for the use of intraluminal shunts in peripheral vascular injury is compelling, and experience in their use is accumulating. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment; resuscitation and prompt revascularization are likely to lead to satisfactory outcomes. The major trauma load in South Africa represents an unparalleled experience in management of vascular injury, which seems likely to continue for the foreseeable future.

Intubated, ventilating patients with complete tracheal transection: a diagnostic challenge.

Tracheal transection is a rare injury after blunt trauma. The presence of complete tracheal transection in the intubated, ventilating patient is even more rare and constitutes a major diagnostic challenge. The liberal use of computed tomography (CT) scans as an adjunct to endoscopy is paramount.

Haemodialysis for post-traumatic acute renal failure - factors predicting outcome.

BACKGROUND: Post-traumatic acute renal failure requiring renal replacement therapy in an intensive care unit (ICU) is associated with high mortality. OBJECTIVE: To assess indicators of improved survival. METHODS: This was a retrospective cohort study of 64 consecutive trauma patients (penetrating and blunt trauma and burns) who underwent haemodialysis (HD) over a period of 5 years. Information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily ICU records were collected. The majority of the patients were dialysed with continuous venovenous haemofiltration in the early years of the study and later with sustained low-efficiency dialysis. RESULTS: Of the 64 patients 47 died, giving an overall mortality rate of 73%. Mortality was highest in the burns patients (84%). Survival in all patients, irrespective of injury, was unrelated to the Revised Trauma Score, Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score or Trauma Injury Severity Score. The duration of HD did not differ significantly between the three trauma groups, and age was not a significant predictor of survival. Patients who were polyuric at the time of the initiation of HD had a lower mortality rate than those who were oliguric, anuric or normouric, although this did not reach statistical significance (p=0.09). CONCLUSIONS: Acute renal failure in trauma patients is associated with a low survival rate. Controversial conclusions have been presented in the literature. In this study, none of the parameters previously reported to affect survival proved to be valid, although the number of patients was comparable with those in other studies. Since understanding of the predictors and course of renal failure in trauma patients is still at an early stage, there is a need for multicentre prospective studies.

Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study.

BACKGROUND: The purpose of this study was to evaluate the effect of the method of splenic injury management on early infectious complications. METHODS: Prospective observational, multicenter study which included all patients with blunt splenic injury surviving at least 72 hours. Epidemiologic and clinical data, grade of splenic injury, method of splenic management, and infectious complications during the initial hospitalization were collected according to a standardized collecting datasheet. Logistic regression analysis was used to identify independent risk factors for infectious complications. RESULTS: During a 22-month period, 269 eligible patients were enrolled in the study. Overall, 105 (39.0%) patients were observed; 48 (17.8%) underwent successful angioembolization, 19 (7.1%) underwent splenorrhaphy, and 97 (36.1%) underwent splenectomy. Multivariate analysis adjusting for age, hypotension on admission, Glasgow Coma Scale, Injury Severity Score, Abbreviated Injury Scale, laparotomy, grade of splenic injury, and associated solid and hollow viscus injuries, showed that splenectomy had a significantly higher incidence of infectious complications than splenic preservation (adjusted odds ratio [95% confidence interval], 9.62 [3.04-30.30]; p < 0.001). A regression model analysis identified splenectomy, hypotension on admission, associated hollow viscus injury, and high Injury Severity Score as independent risk factors for infectious complications. Forward logistic regression analysis, which included only the 176 patients with grades III to V splenic injuries, identified splenectomy as the most significant independent risk factors for infection (adjusted odds ratio [95% confidence interval], 16.67 [3.76-71.43]; p < 0.001). CONCLUSIONS: Splenectomy is an independent risk factor for early infectious complications. Splenic-preserving techniques should be considered more liberally.

A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries.

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome.