Incidence, mortality, and predictive factors associated with acute respiratory distress syndrome in multiple trauma patients living in high-altitude areas: a retrospective study in Shigatse.

Background: Acute respiratory distress syndrome (ARDS) is a severe complication that can lead to fatalities in multiple trauma patients. Nevertheless, the incidence rate and early prediction of ARDS among multiple trauma patients residing in high-altitude areas remain unknown. Methods: This study included a total of 168 multiple trauma patients who received treatment at Shigatse People's Hospital Intensive Care Unit (ICU) between January 1, 2019 and December 31, 2021. The clinical characteristics of the patients and the incidence rate of ARDS were assessed. Univariable and multivariable logistic regression models were employed to identify potential risk factors for ARDS, and the predictive effects of these risk factors were analyzed. Results: In the high-altitude area, the incidence of ARDS among multiple trauma patients was 37.5% (63/168), with a hospital mortality rate of 16.1% (27/168). Injury Severity Score (ISS) and thoracic injuries were identified as significant predictors for ARDS using the logistic regression model, with an area under the curve (AUC) of 0.75 and 0.75, respectively. Furthermore, a novel predictive risk score combining ISS and thoracic injuries demonstrated improved predictive ability, achieving an AUC of 0.82. Conclusions: This study presents the incidence of ARDS in multiple trauma patients residing in the Tibetan region, and identifies two critical predictive factors along with a risk score for early prediction of ARDS. These findings have the potential to enhance clinicians' ability to accurately assess the risk of ARDS and proactively prevent its onset.

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.

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.

Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine.

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.

Silencing CD28 attenuated chest blast exposure-induced traumatic brain injury through the PI3K/AKT/NF-κB signaling pathway in male mice.

In modern war or daily life, blast-induced traumatic brain injury (bTBI) is a growing health concern. Our previous studies demonstrated that inflammation was one of the main features of bTBI, and CD28-activated T cells play a central role in inflammation. However, the mechanism of CD28 in bTBI remains to be elucidated. In this study, traumatic brain injury model induced by chest blast exposure in male mice was established, and the mechanism of CD28 in bTBI was studied by elisa, immunofluorescence staining, flow cytometry analysis and western blot. After exposure to chest shock wave, the inflammatory factors IL-4, IL-6 and HMGB1 in serum were increased, and CD3+ T cells, CD4+ and CD8+ T cell subsets in the lung were activated. In addition, chest blast exposure resulted in impaired spatial learning and memory ability, disruption of the blood-brain barrier (BBB), and the expression of Tau, p-tau, S100ß and choline acetyltransferase were increased. The results indicated that genetic knockdown of CD28 could inhibit inflammatory cell infiltration, as well as the activation of CD3+ T cells, CD4+ and CD8+ T cell subsets in the lung, improve spatial learning and memory ability, and ameliorate BBB disruption and hippocampal neuron damage. Moreover, genetic knockdown of CD28 could reduce the expression of p-PI3K, p-AKT and NF-κB. In conclusion, chest blast exposure could lead to bTBI, and attenuate bTBI via the PI3K/AKT/NF-κB signaling pathway in male mice. This study provides new targets for the prevention and treatment of veterans with bTBI.

Thoracic Ultrasound for Detection of Pneumothorax Following Thoracostomy Tube Removal in Trauma Patients.

INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.

Return to work and activity after rib-fixation for acute chest trauma: first application of a validated patient-reported outcomes assessment tool.

OBJECTIVES: Rib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilization of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature. METHODS: A retrospective review was conducted on patients with rib fractures requiring surgical fixation in a single centre between 2008 and 2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient-reported outcome measure questionnaires. RESULTS: Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and 31 completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased postoperatively from 22 to 16 (P = 0.006). For those who returned to work, there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score postoperatively. CONCLUSIONS: Approximately 1 in 5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return-to-work outcomes in trauma patients.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population. METHODS: A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF. RESULTS: A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis. CONCLUSION: Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Favourable outcome in survivors of CPR-related chest wall injuries.

BACKGROUND: There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest. METHODS: Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing. RESULTS: The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups. CONCLUSION: None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.

Comparison between Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality of thoracic trauma in a tertiary hospital.

INTRODUCTION: measuring the severity of traumatic injuries is crucial for predicting clinical outcomes. Whereas the Injury Severity Score (ISS) has limitations in assigning scores to injuries at the same site, the New Injury Severity Score (NISS) corrects for this problem by taking into account the three most severe injuries regardless of the region of the body. This study seeks to comprehend the clinical and epidemiological profile of trauma patients while comparing the effectiveness of scales for predicting mortality. METHODS: a descriptive, observational and retrospective study using records of patients who underwent thoracotomy at the Hospital das Clínicas of the Federal University of Triângulo Mineiro between 2000 and 2019. Demographic data, mechanisms of injury, affected organs, length of stay and mortality were analyzed. Injury severity was assessed using the ISS and NISS, and statistical analyses were conducted using MedCalc and SigmaPlot. RESULTS: 101 patients were assessed, on average 29.6 years old, 86.13% of whom were men. The average duration of hospitalization was 10.9 days and the mortality rate was 28.7%. The ROC curve analysis revealed a sensitivity of 68.97%, specificity of 80.56% and area under the curve of 0.837 for the ISS, and 58.62%, 94.44% and 0.855 for the NISS, respectively. The Youden index was 0.49 for the ISS and 0.53 for the NISS. CONCLUSION: the study demonstrated comparable efficacy of NISS and ISS in predicting mortality. These findings hold significance in the hospital setting. Professionals must be familiar with these scales to utilize them competently for each patient.

[A Review of 70 Cases of Thoracic Trauma with Rib Fixation:Indications and Practical Innovations of the Procedure].

We summarized the experience of surgical stabilization of rib fractures (SSRF) at a core hospital in eastern Hiroshima, which is a primary center for tertiary emergency medical care, especially for high-energy trauma cases including chest injuries. The study focuses on patients who underwent SSRF from January 2016 to September 2023, analyzing patient characteristics, injury mechanisms, associated injuries, fracture locations, time from injury to surgery, fixation devices used, and postoperative outcomes. Our hospital primarily treats elderly patients, and falls are the most common cause of injury, followed by traffic accidents. The criteria for SSRF in our hospital were clinical manifestations of flail chest, need for lung repair, persistent pain, or improvement of thoracic deformity. We had a high rate of fixation of fractures of the 4th-10th ribs, which have a significant impact on respiratory mechanics; although KANI plates were primarily used, the introduction of MatrixRIB plates offers advantages in certain scenarios. The study also identified challenges with the KANI plate, including cases of plate dislodgement, particularly in patients with multiple fractures and severe thoracic deformities. The combination of video-assisted thoracoscopic surgery and SSRF allows for more effective rib fixation and reduces surgical wound size and muscle damage.

[Video-assisted Thoracoscopic Surgery for Chest Trauma].

Video-assisted thoracoscopic surgery (VATS) is now commonly used in emergency surgery to confirm the site of injury and observe the thoracic cavity, especially in cases of chest trauma with stable vital signs. VATS was used in all 33 chest trauma surgeries performed at our department from October 2009 to July 2023. The common injury mechanisms were traffic trauma and falls, but there were also cases of trauma from a bullhorn, heavy machinery and farm equipment, and penetrating injury. The common surgical procedures were treatment of rib fractures and pulmonary suture or partial lung resection, followed by treatment of diaphragmatic injuries. Unusual surgical procedures included extrapleural hematoma drainage, pericardial drainage, hemostasis of intrathoracic bleeding from thoracic vertebral fracture, and lobectomy for airway bleeding. Here, we report our surgical policies and techniques for chest trauma. First, the thoracic cavity should be observed thoracoscopically to determine the site of injury. The key to repair is placement of a small thoracotomy directly above the rib fracture site, where dislocation is largest, followed by suture repair of the lung and diaphragm by combining direct and thoracoscopic views.

[Outcomes of Surgical Treatment for Chest Trauma].

BACKGROUND: Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. METHOD: We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. RESULTS: All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. CONCLUSIONS: Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

[Traumatic damage to the diaphragm in children]. / Travmaticheskie povrezhdeniya diafragmy u detei.

OBJECTIVE: To analyze treatment outcomes in children with traumatic injuries of the diaphragm. MATERIAL AND METHODS: We followed-up 14 children aged 3-18 years with traumatic injuries of the diaphragm. Diagnostic measures included anamnesis, physical examination, pleural and abdominal puncture, bladder catheterization, ultrasound and X-ray examination including CT. RESULTS: Traumatic brain injury and thoracoabdominal trauma prevailed in children with traumatic injuries of the diaphragm. In 8 children, diaphragm injury was the result of a traffic accident. Of these, 5 ones died at the scene due to traumatic brain injury. In 3 children, diaphragm injury was associated with penetration of an iron pin through the perineum, pelvic cavity, abdominal and chest cavities when falling from a height (n=1) and sledding (n=2). Two children were littered with a pile of bricks and building materials. One girl suffered a diaphragm injury as a result of a stab wound. CONCLUSION: Combined damage to the diaphragm, TBI, chest and abdominal organs are serious injuries. Signs of shock, internal bleeding, respiratory failure and bone fractures come to the fore. Assistance to these children should be carried out in specialized hospitals.

Validated numerical unrestrained occupant-seat crash scenarios for high-speed trains integrating experimental, computational, and inverse methods.

OBJECTIVE: Occupant impact safety is critical for train development. This paper proposes a systematic procedure for developing validated numerical occupant crash scenarios for high-speed trains by integrating experimental, computational, and inverse methods. METHODS: As the train interior is the most potentially injury-causing factor, the material properties were acquired by mechanical tests, and constitutive models were calibrated using inverse methods. The validity of the seat material constitutive model was further verified via drop tower tests. Finite element (FE) and multibody (MB) models of train occupant-seat interactions in frontal impact were established in LS-DYNA and MADYMO software, respectively, using the experimentally acquired materials/mechanical characteristics. Three dummy sled crash tests with different folding table and backrest configurations were conducted to validate the numerical occupant-seat models and to further assess occupant injury in train collisions. The occupant impact responses between dummy tests and simulations were quantitatively compared using a correlation and analysis (CORA) objective rating method. RESULTS: Results indicated that the experimentally calibrated numerical seat-occupant models could effectively reproduce the occupant responses in bullet train collisions (CORA scores >80%). Compared with the train seat-occupant MB model, the FE model could simulate the head acceleration with slightly more acceptable fidelity, however, the FE model CORA scores were slightly less than for the MB models. The maximum head acceleration was 30 g but the maximum HIC score was 17.4. When opening the folding table, the occupant's chest injury was not obvious, but the neck-table contact and "chokehold" may potentially be severe and require further assessment. CONCLUSIONS: This study demonstrates the value of experimental data for occupant-seat model interactions in train collisions and provides practical help for train interior safety design and formulation of standards for rolling stock interior passive safety.

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.

The effects of postural support padding modifications to child restraints for children with disability on crash protection.

OBJECTIVE: Many children with physical disabilities need additional postural support when sitting and supplementary padding is used on standards approved child restraints to achieve this when traveling in a motor vehicle. However, the effect of this padding on crash protection for a child is unknown. This study aimed to investigate the effect of additional padding for postural support on crash protection for child occupants in forward facing child restraints. METHODS: Forty frontal sled tests at 49 km/h were conducted to compare Q1 anthropometric test device (ATD) responses in a forward-facing restraint, with and without additional padding in locations to increase recline of the restraint, and/or support the head, trunk and pelvis. Three padding materials were tested: cloth toweling, soft foam, and expanded polystyrene (EPS). The influence of padding on head excursion, peak 3 ms head acceleration, HIC15, peak 3 ms chest acceleration and chest deflection were analyzed. RESULTS: The influence of padding varied depending on the location of use. Padding used under the restraint to increase the recline angle increased head injury metrics. Toweling in multiple locations which included behind the head increased head excursion and chest injury metrics. There was minimal effect on injury risk measures with additional padding to support the sides of the head or the pelvis position. Rigid EPS foam, as recommended in Australian standards and guidelines, had minimal effect on injury metrics when used inside the restraint, as did tightly rolled or folded toweling secured to the restraint at single locations around the body of the child. CONCLUSIONS: This study does not support the use of postural support padding to increase recline of a forward-facing restraint or padding behind the head. Recommendations in published standards and guidelines to not use foam that is spongy, soft or easily compressed, with preference for secured firm foam or short-term use of tightly rolled or folded toweling under the child restraint cover is supported. This study also highlights the importance of considering the whole context of child occupant protection when using additional padding, particularly the change in the child's seated position when adding padding in relation to the standard safety features of the restraint.

Trivial trauma to the cheek: significant complications in the chest.

A man in his 30s presented to the emergency department with a history of injury to the face with a crowbar. He was discharged from the department, in the absence of any facial bone fractures and given normal examination findings, except for a puncture wound on the mentum. The patient then re-presented within 24 hours with extensive cervical emphysema extending into the mediastinal cavity.He was referred to ear, nose and throat team for further management. CT scan of the chest and neck showed extensive surgical emphysema and a pneumomediastinum. The patient was managed conservatively and recovered well with no significant sequelae.Even in the absence of facial bone fractures, it is imperative to understand the force of impact which should prompt a consideration of imaging of the chest. Appropriate advice regarding avoidance of Valsalva manoeuvres will help prevent extensive propagation of air through the fascial planes that can result in a pneumomediastinum.