[Penetrating Lung Injury Complicated by Hemodynamic Cerebral Infarction].

We encountered a case in which emergency surgery was performed for a penetrating lung injury complicated by a hemodynamic cerebral infarction. A 45-year-old man sustained a chest injury due to a scattered piece of metal and was admitted to a nearby hospital. He was confirmed to have hemorrhagic shock due to a right hemopneumothorax, and a chest tube was inserted he was transferred to our hospital. Chest radiography and computed tomography (CT) revealed a metal fragment in the right lung and confirmed the diagnosis of a penetrating lung injury due to a foreign body. The patient also presented with total blindness of an unknown etiology. Emergency surgery was performed to treat the injury and remove the foreign body. A large amount of blood and hematoma were removed from the right thoracic cavity, and a metal fragment was found in the lower lobe of the right lung. After removing the foreign body, pulmonary suturing was performed. On the following day, head magnetic resonance imaging revealed multiple cerebral infarctions in the bilateral occipital lobes, left frontal lobe, and left cerebellar hemisphere. However, no vascular occlusion or thrombus was found, and the patient was diagnosed with hemodynamic cerebral infarction due to hemorrhagic shock.

Endovascular treatment for 2 types of subclavian artery injury: A case report.

RATIONALE: Subclavian artery (SCA) injuries, though rare, carry significant morbidity and mortality risks due to significant blood loss causing hypovolemic shock. Early diagnosis and adequate treatment are crucial to minimize bleeding and associated morbidity. Recent advances in endovascular techniques offer faster and more accurate treatment options compared to traditional open surgical repair. This study demonstrates the efficacy of endovascular treatment in 2 cases of SCA injury and reviews its indications, limitations, and precautions. PATIENT CONCERNS: A 69-year-old man presented with a penetrating SCA injury from a steel bar, and a 38-year-old woman presented with a blunt SCA injury caused by a fall. Both patients were hemodynamically unstable upon presentation. DIAGNOSES: Both patients were diagnosed with SCA injuries. The man had a penetrating injury, while the woman had a blunt injury, both resulting in hemodynamic instability and significant risk of hypovolemic shock. INTERVENTIONS: Endovascular techniques, including the use of covered stent grafts, were employed to manage the injuries. These techniques allowed for rapid and efficient treatment, reducing the need for open surgical intervention. OUTCOMES: Both patients were successfully treated using endovascular methods and were discharged without any complications. The endovascular approach minimized blood loss, transfusion needs, and hospital stay. LESSONS: This study demonstrates the effectiveness of endovascular techniques in rapidly diagnosing, bridging, and definitively treating SCA injuries, suggesting their use as a first-line therapy.

Focused assessment with sonography for trauma exam for diagnosis of pericardial effusion in penetrating thoracic trauma - A retrospective review from a level 1 trauma center.

INTRODUCTION: Point of care ultrasound has long been used in the trauma setting for rapid assessment and diagnosis of critically ill patients. Its utility for diagnosis of pericardial effusion in the setting of penetrating thoracic trauma has more recently been a topic of consideration, given the rapid decompensation that these patients can experience. OBJECTIVES: This study aims to identify the diagnostic accuracy of point of care ultrasound in the diagnosis of pericardial effusion among patients with penetrating thoracic trauma. METHODS: Retrospective review of 2099 patients brought to the trauma bay between the years 2016 and 2021 were analyzed for diagnosis of pericardial effusion. Patients who were diagnosed with a pericardial effusion were investigated for point of care ultrasound findings. Descriptive statistics were performed to identify sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Prevalence was calculated to be 26.7 cases of pericardial effusion per 1000 patients presenting with penetrating thoracic trauma. Incidence was estimated to be 3.8 cases of pericardial effusion per 1000 person-years. Calculation of diagnostic capabilities of ED POCUS revealed a sensitivity of 96.36 â€‹%, a specificity of 100 â€‹%, PPV of 100 â€‹%, and NPV of 99.90 â€‹%. CONCLUSIONS: Point of Care cardiac ultrasonography is a reliable tool for the rapid diagnosis of pericardial effusion in penetrating thoracic trauma patients. Patients with ultrasound suggestive of this condition should receive rapid surgical management to prevent decompensation.

Directed work-up of select penetrating neck injuries is safe: Hard signs continue to soften.

INTRODUCTION: Management of penetrating neck injuries (PNIs) has evolved over time, more frequently relying on increased utilization of diagnostic imaging studies. Directed work-up with computed tomography imaging has resulted in increased use of angiography and decreased operative interventions. We sought to evaluate management strategies after directed work-up, hypothesizing increased use of non-operative therapeutic interventions and lower mortality after directed work-up. METHODS: Patients with PNI from 2017 to 2022 were identified from a single-center trauma registry. Demographics, injuries, physical exam findings, diagnostic studies and interventions were collected. Patients were stratified by presence of hard signs and management strategy [directed work-up (DW) and immediate operative intervention (OR)] and compared. Outcomes included therapeutic non-operative intervention [endovascular stent, embolization, dual antiplatelet therapy (DAPT), or anticoagulation (AC)], non-therapeutic neck exploration, length of stay (LOS), and mortality. RESULTS: Of 436 patients with PNI, 143 (33%) patients had vascular and/or aerodigestive injuries. Of these, 115 (80%) patients underwent DW and 28 (20%) patients underwent OR. There were no differences in demographics or injury severity score between groups. Patients in the DW group were more likely to undergo vascular stent or embolization (p = 0.040) and had fewer non-therapeutic neck explorations (p = 0.0009), compared to the OR group. There were no differences in post-intervention stroke, leak, or mortality. Sixty percent of patients with vascular hard signs and 78% of patients with aerodigestive hard signs underwent DW. CONCLUSIONS: Directed work-up in select patients with PNI is associated with fewer non-therapeutic neck explorations. There was no difference in mortality. Selective use of endovascular management, AC and DAPT is safe.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes.

BACKGROUND: Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries. METHODS: Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation. RESULTS: 243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation. DISCUSSION: Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

Complicated penetrating foreign body neck injury.

Penetrating neck injury is associated with significant morbidity due to the several structures (neurological, vascular and aerodigestive) within close proximity to one another. This case highlights an uncommon presentation of an embedded foreign body following penetrating neck trauma and the decision-making required during management.

Risk Factors for Empyema Following Penetrating Diaphragmatic Injuries.

Empyema resulting as a complication of penetrating diaphragmatic injuries is a subject that requires further investigation, and the aim of this study was to determine the risk factors associated with empyema in patients with penetrating trauma. Consecutive adult trauma patients from a level 1 trauma center were searched for penetrating diaphragm injuries. Data were collected on patient demographics, pre-existing conditions, injury type and severity, hospital interventions, in-hospital complications, and outcomes. Patients were stratified by empyema formation and univariant analyses were performed. 164 patients were identified, and 17 patients (10.4%) developed empyema. Empyema was associated with visible abdominal contamination (35.3% vs 15%, P = .04), thoracotomy (35.5% vs 13.6%, P = .03), pneumonia (41.2% vs 14.3%, P = .01), sepsis (35.3% vs 8.8%, P = .006), increased hospital length of stay (25.5 vs 10.1 days, p =<.001), increased intensive care unit length of stay (9.6 vs 4.3 days, P = .01), and decreased in-hospital mortality (0% vs 20.4%, P = .04).

Obesity and Associated Outcomes for Blunt vs Penetrating Mechanism in Trauma Laparotomy Patients.

Obesity in trauma patients is an established risk factor contributing to postoperative complications, but the relationship between body mass index (BMI) and trauma patient outcomes is not well-defined, especially when stratified by mechanism of injury. We surveyed the trauma laparotomy registry at an academic level 1 trauma center over a 3-year period to identify mortality, injury severity score, and hospital length of stay (hLOS) outcome measures across BMI classes, with further stratification by mechanism of injury: blunt vs penetrating trauma. A total of 442 patients were included with mean age 44.6 (SD = 18.7) and mean BMI 28.55 (SD = 7.37). These were subdivided into blunt trauma (n = 313) and penetrating trauma (n = 129). Within the blunt trauma subgroup, the hLOS among patients who survived hospitalization significantly increased 9% for each successive BMI class (P = .022, 95% CI = 1.29-17.5). We conclude that successive increase in BMI class is associated with longer hospital stay for blunt trauma patient survivors requiring laparotomy, though additional analysis is needed to establish this relationship to other outcome measures and among penetrating trauma patients.

Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Management of contained penetrating cardiac injury in a patient with prior cardiac surgery.

Penetrating cardiac injuries usually require emergent surgical intervention. Our patient presented to the trauma centre with multiple stab wounds to the neck, chest, epigastric region and abdomen. She arrived haemodynamically stable, and her initial Focused Assessment with Sonography for Trauma exam was negative. Her chest X-ray did not show any evident pneumothorax or haemothorax. Due to her injury pattern, she was taken to the operating room for exploratory laparotomy and neck exploration. Postoperatively, she was taken for CT and found to have a contained cardiac rupture. The injury was contained within previous scar tissue from her prior cardiac surgery. Further evaluation revealed that the injury included a penetrating stab wound to the right ventricle and a traumatic ventricular septal defect (VSD). She subsequently underwent a redo sternotomy with the repair of the penetrating stab wound and the VSD. Cardiology, intensive care, trauma surgery and cardiothoracic surgery coordinated her care from diagnosis, management and recovery. This case highlights the challenges in the management of cardiac injuries and the benefits of a multidisciplinary approach to care for complex cardiac injuries.

Characteristics of traumatic major haemorrhage in a tertiary trauma center.

BACKGROUND: Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma. METHODS: This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission. RESULTS: In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality. RESULTS: Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.

Patterns of firearm related injury in the elderly: A single institution analysis.

BACKGROUND: Firearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic. METHODS: A retrospective review of the trauma registry at a large Level I center was performed from 2016-2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18-64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition. RESULTS: 23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7-93.1] compared to 63.7 [IQR 33.2-83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in "at risk" or "distressed" communities. CONCLUSION: FRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Prognostic Significance of Multifactorial Analysis in Complex Cervical Aero-Digestive Trauma Cases.

Background and Objectives: In the context of complex aerodigestive cervical traumas, the prognosis and outcome heavily depend on risk factors, particularly injuries to the larynx, trachea, major digestive tissues, cervical vertebrae, and vascular structures. With the increasing prevalence of trauma as a public health concern, there is a pressing need for epidemiological research and the implementation of preventative measures. The purpose of this research is to establish the profile of the predictable impact factors that determine the prognosis of patients with complex cervical trauma. Methods and Methods: The study group consisted of 106 patients with complex cervical trauma pathology developed by various mechanisms such as car accidents, home-related accidents, aggression, gunshot wounds, and self-inflicted attempts, resulting in hospitalization in the E.N.T. Clinic at "St. Spiridon" Iași Hospital, from 2012 to 2016; medical records were the source of the collected data. Results: Hemodynamic instability upon admission associated with age, muscle and laryngeal injuries, and anemia were identified as negative prognostic factors. Additionally, the utilization of imaging-based paraclinical investigations for diagnosing traumatic lesions emerged as a positive prognostic factor in managing this pathology. The management of penetrating cervical trauma remains a subject of debate, with some advocating for surgical exploration beyond the platysma layer in all cases, while others argue for a more selective conservative approach due to a high rate of negative explorations. Conclusions: The statistical evaluation of epidemiological, clinical, lesion, paraclinical, and therapeutic parameters is needed to establish predictable risk factors in the prognosis of complex aerodigestive cervical trauma.

Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials.

Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.

Clinical Reasoning: A 24-Year-Old Woman With Penetrating Neck Injury From a Needlefish.

Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.

Anterior approach for a stab wound with penetrating rebar injury causing incomplete cauda equina syndrome in lumbosacral spine lesion: a case report and literature review.

PURPOSE: To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach. METHODS: Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal. RESULTS: By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up. CONCLUSION: It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets.

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Aids in the Successful Non-Operative Management of a Life-Threatening Penetrating Liver Injury.

In recent years, isolated non-operative management of penetrating liver injuries has become the standard of care for the hemodynamically stable patient. However, when the patient becomes hemodynamically unstable, adjuncts such as resuscitative endovascular balloon occlusion of the aorta (REBOA) deployed in Zone 1 can be used to achieve complete aortic occlusion from the celiac axis down. Unfortunately, hemorrhage control through REBOA comes at the risk of deadly intra-abdominal ischemia. Partial REBOA (pREBOA) introduces the opportunity to make targeted changes in volume and thus titrate the amount of aortic occlusion in real-time to adequately manage hemorrhage while allowing some distal blood flow. This is a novel approach and one which may give providers more time to gain definitive hemorrhage control while minimizing the morbidity of ischemia. Here, we present a case of life-threatening penetrating liver injury that was successfully managed non-operatively with the assistance of p-REBOA.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017.

BACKGROUND: Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. METHODS: For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. RESULTS: We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. CONCLUSIONS: Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. TRIAL REGISTRATION: Retrospective analysis without intervention.

Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma.

INTRODUCTION: Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS: A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS: We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS: Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Pediatric case of a penetrating lumbar spinal injury.

PURPOSE: Penetrating spinal injuries are generally extremely rare and are seldom encountered in pediatric patients. The non-compliance of pediatric patients with physical examination can sometimes delay diagnosis and treatment. Here, we present a case of a child who had a fall and suffered penetrating spinal trauma due to a small glass fragment. CASE REPORT: A penetrating foreign body was detected in the lumbar spinal region of a 2-year-old patient with complaints of increased restlessness on physical activity followed by difficulty in walking. The patient was operated on and followed up without any complications in the perioperative and late postoperative periods. CONCLUSION: A detailed physical examination is necessitated in the pediatric age group because of insufficient anamnesis. The high number of patients per physician, especially in societies having a low socioeconomic standard, prevents detailed examinations, and unnecessary examinations may cause delays in diagnosis. However, one must note that the skin findings of pediatric patients can be very helpful, especially in pediatric neurosurgery, and examination should not be neglected.