Rib and sternum fracture risks for restrained occupants in frontal car crashes.

OBJECTIVE: Most car occupant fatalities occur in frontal crashes and the thorax is the most frequently injured body region. The objectives of the study were, firstly, to quantify the relation between risk factors (such as speed and occupant age) and rib and sternum fracture injury probability in frontal car crashes, and, secondly, to evaluate whether rib fracture occurrence can predict sternum fractures. METHODS: Weighted German data from 1999-2021 were used to create the injury risk curves to predict both, at least moderate and at least serious, rib and sternum fracture risks. A contingency table for rib and sternum fractures allowed the calculation of sensitivity, specificity, and precision, as well as testing for the association. RESULTS: Elderly occupants (≥65 years old) had increased rib and sternum fracture risk compared to mid aged occupants (18-64 years old). Besides occupant age, delta-V was always and sex sometimes a significant predictor for skeletal thoracic injury. Sternum fractures were more common than rib fractures and more likely to occur at any given delta-V. Sternum fractures occurred often in isolation. Female occupants were at higher risk than males to sustain at least moderate rib and sternum fractures together and sternum fractures in isolation. Rib and sternum fractures were associated, but low sensitivity and precision show that rib fractures do not predict sternum fractures well. CONCLUSIONS: Elderly and female occupants were at the highest risk and should be targeted by thoracic injury criteria and thresholds for frontal crash occupant protection. Rib and sternum fractures were not associated. Therefore, sternum fractures need to be predicted and evaluated separately from rib fractures.

Mortality of traumatic chest injury and its predictors across sub-saharan Africa: systematic review and meta-analysis, 2024.

INTRODUCTION: Globally, chest trauma remain as a prominent contributor to both morbidity and mortality. Notably, patients experiencing blunt chest trauma exhibit a higher mortality rate (11.65%) compared to those with penetrating chest trauma (5.63%). AIM: This systematic review and meta-analysis aimed to assess the mortality rate and its determinants in cases of traumatic chest injuries. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the data synthesis process. Multiple advanced search methods, encompassing databases such as PubMed, Africa Index Medicus, Scopus, Embase, Science Direct, HINARI, and Google Scholar, were employed. The elimination of duplicate studies occurred using EndNote version X9. Quality assessment utilized the Newcastle-Ottawa Scale, and data extraction adhered to the Joanna Briggs Institute (JBI) format. Evaluation of publication bias was conducted via Egger's regression test and funnel plot, with additional sensitivity analysis. All studies included in this meta-analysis were observational, ultimately addressing the query, what is the pooled mortality rate of traumatic chest injury and its predictors in sub-Saharan Africa? RESULTS: Among the 845 identified original articles, 21 published original studies were included in the pooled mortality analysis for patients with chest trauma. The determined mortality rate was nine (95% CI: 6.35-11.65). Predictors contributing to mortality included age over 50 (AOR 3.5; 95% CI: 1.19-10.35), a time interval of 2-6 h between injury and admission (AOR 3.9; 95% CI: 2.04-7.51), injuries associated with the head and neck (AOR 6.28; 95% CI: 3.00-13.15), spinal injuries (AOR 7.86; 95% CI: 3.02-19.51), comorbidities (AOR 5.24; 95% CI: 2.93-9.40), any associated injuries (AOR 7.9; 95% CI: 3.12-18.45), cardiac injuries (AOR 5.02; 95% CI: 2.62-9.68), the need for ICU care (AOR 13.7; 95% CI: 9.59-19.66), and an Injury Severity Score (AOR 3.5; 95% CI: 10.6-11.60). CONCLUSION: The aggregated mortality rate for traumatic chest injuries tends to be higher in sub-Saharan Africa. Factors such as age over 50 years, delayed admission (2-6 h), injuries associated with the head, neck, or spine, comorbidities, associated injuries, cardiac injuries, ICU admission, and increased Injury Severity Score were identified as positive predictors. Targeted intervention areas encompass the health sector, infrastructure, municipality, transportation zones, and the broader community.

Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study.

BACKGROUND: A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma. METHODS: This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV. RESULTS: The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days. CONCLUSIONS: Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.

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.

Effects of the response to the COVID-19 pandemic in chest trauma patients in China: a multicenter retrospective study.

BACKGROUND: An international pandemic of severe coronavirus disease (COVID-19) has been caused by the novel coronavirus SARS-CoV-2. A large number of patients with chest trauma were infected with COVID-19. The COVID-19 pandemic had a significant impact on the management of chest trauma. OBJECTIVE: The present observational study was conducted to evaluate the clinical characteristics and outcomes of chest trauma patients with or without COVID-19 infection. METHODS: A multicenter observational study was performed at three Chinese hospitals between November 1, 2022, and January 31, 2023. All enrolled patients were diagnosed with chest trauma. We analyzed data from existing medical records, including all baseline data and prognostic follow-up data, such as 30-day mortality, hospital stays, hospitalization costs, and complications. RESULTS: All 375 eligible patients completed the follow-up. There was no significant difference in baseline characteristics between chest trauma combined with COVID-19 (p > 0.05). Chest trauma combined with COVID-19 infection may lead to higher 30-day mortality (16.36% vs. 7.14%, p = 0.005), longer hospital stays (22.5 ± 5.9 vs. 12.8 ± 4.2, p < 0.001), larger hospitalization costs (p < 0.001), and increased hospitalization complications, such as pulmonary embolism (10.30% vs. 4.76%, p = 0.039), deep vein thrombosis (DVT, 33.33% vs. 18.57%, p = 0.001), the incidence of 7-day delirium (69.70% vs. 46.19%, p < 0.001), and respiratory failure (38.18% vs. 24.77%, p = 0.005). CONCLUSIONS: Compared to chest trauma alone, it may lead to higher mortality, larger hospitalization costs, and more complications. To better respond to the future of COVID-19 or other similar virus-borne disease pandemics, it is important to understand the clinical characteristics and complications, such as pulmonary embolism, DVT, and respiratory failure after COVID-19 infection. To guide the future treatment of chest trauma combined with COVID-19 infection or other infectious diseases.

Clinical-epidemiological evaluation of victims of thoracic trauma in a reference hospital in Aracaju-SE.

INTRODUCTION: thoracic trauma is defined as anything that involves the rib cage, the musculoskeletal framework that houses the heart, lungs, pleurae and mediastinal structures. It can be superficial or immediately lifethreatening for victims. In Brazil, most assistance is due to urban violence. OBJECTIVE: evaluate the clinical and epidemiological aspect of patients who are victims of thoracic trauma treated at Hospital de Urgência de Sergipe, Aracaju/SE, Brazil. METHOD: cross-sectional, observational and prospective study, carried out for eleven months, with 100 polytraumatized patients. A semi-structured form was applied, and the data were systematized, analyzed and statistically tested considering a 5% margin of error. Results: 85% of the patients were male, with a mean age of 39.3 and an age range of 30 to 49 years; 57% of them had incomplete primary education, 70% had a family income of up to 2 minimum wages and 41% were from Greater Aracaju. As for the mechanism of trauma, 33% were car-related, with blunt trauma as the main mechanism, and rib fractures as the main consequence. Among penetrating injuries, CWI (26%) and GSW (21%) were the most prevalent, with hemothorax being the main consequence. Most patients underwent thoracostomy (59%). CONCLUSION: the profile found was of young men, victims of urban violence. The thoracostomy was resolving in most cases and should be instituted promptly when necessary. A smaller number of patients may require thoracotomy, especially in the presence of hemodynamic instability.

Clinical features and treatment of thoracic trauma in children. Eleven years of experience in a single center.

AIM: This study aims to evaluate the characteristics of thoracic trauma in children. MATERIAL AND METHOD: Thoracic trauma cases treated in our clinic between February 2011 and January 2022 were retrospectively analyzed. RESULTS: 31.5% (n=136) of 432 cases with thoracic trauma had isolated thoracic trauma. Mean age was 8.7±4 years, 74.3% were boys (n=321) and 25.7% were girls (n=111). In patients with thoracic trauma in children; blunt injuries were 84%, penetrating-stab wounds were 12%, and gunshot wounds were 4%, while the rate of penetrating trauma over the age of 15 was 24.8%. The most common causes were motor vehicle accidents (42.4%) and falls from height (23.9%). The most common pathologies; pulmonary contusion (71.7%), pneumothorax (48.7%), rib fracture (18%), and pulmonary laceration (12%). Tube thoracostomy was performed in 51 (46.4%) of 110 cases with pneumothorax. Thoracotomy was performed in 2 cases with penetrating gunshot wounds, and tube thoracostomy was performed in 2 cases with hemothorax. The mean hospital stay was 7 days, and1 case with severe cranial trauma died. CONCLUSION: Chest wall, pulmonary, mediastinal, and diaphragmatic structures can be damaged in chest trauma. However, it should be kept in mind that every chest trauma patient may also have polytrauma, and accompanying injuries should be carefully examined. KEY WORDS: Childhood, Thoracic trauma, Tube Thoracostomy.

Analysis of diagnoses of chest injuries in a Nigerian trauma center.

Background: Chest injury is one of the most common types of trauma-related injuries accounting for about 10% of trauma admissions in emergency services. The injuries may be immediate, life-threatening, or potentially life-threatening based on diagnosis after initial assessment. This study is intended to analyze the pattern of diagnosis found in chest-injured patients in a trauma center of a developing country. Methods: This is a retrospective study carried out in the trauma center of the National Hospital Abuja, Nigeria, between January 2015 and December 2017, as an analysis of the existing trauma registry. Data procession was done using SPSS version 24.0. Results were presented in tables and figures. Results: A total of 637 patients' data was studied, male to female ratio of 3.58 and mean age of 34.18 ± 11.34 years. More patients sustained isolated chest injury (59.5%) and blunt chest injury (78%). The most frequent diagnosis was chest wall soft tissue injury (CWSTI) (46.6%) despite the exclusion of minor chest wall injuries who did not require any form of observation. Haemothorax and rib fractures were the next most common diagnoses after CWSTI constituting 13.5% and 8.7%, respectively, while flail chest and aortic injuries were the least comprising 0.6% and 0.2%, respectively. The commonest associated injuries were traumatic brain injury (11.3%), extremity fractures (11.1%), and abdominal injuries (7.8%). Penetrating injuries were more significantly associated with male gender and isolated chest injuries (P < 0.001). Conclusion: Chest wall soft tissue injuries constitute a large proportion of chest injuries seen in our setting. Despite its relatively low importance in the medical literature, it should be given attention in resource-poor settings in order to minimize missed significant injuries in the absence of diagnostic facilities. Therefore, high index of suspicion and low threshold for observation should be practiced in this group of patients.

A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on motor vehicle crashes: Logistic regression approach.

OBJECTIVE: Chest injuries that occur in motor vehicle crashes (MVCs) include rib fractures, pneumothorax, hemothorax, and hemothorax depending on the injury mechanism. Many risk factors are associated with serious chest injuries from MVCs. The Korean In-Depth Accident Study database was analyzed to identify risk factors associated with motor vehicle occupants' serious chest injury. METHODS: Among 3,697 patients who visited the emergency room in regional emergency medical centers after MVCs between 2011 and 2018, we analyzed data from 1,226 patients with chest injuries. Vehicle damage was assessed using the Collision Deformation Classification (CDC) code and images of the damaged vehicle, and trauma scores were used to determine injury severity. Serious chest injury was defined as an Abbreviated Injury Scale (AIS) score for the chest code was more than 3. The patients were divided into two groups: serious chest injury patients with MAIS ≥ 3 and those with non-serious chest injury with MAIS < 3. A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on MVCs was constructed by a logistic regression analysis. RESULTS: Among the 1,226 patients with chest injuries, 484 (39.5%) had serious chest injuries. Patients in the serious group were older than those in the non-serious group (p=.001). In analyses based on vehicle type, the proportion of light truck occupants was higher in the serious group than in the non-serious group (p=.026). The rate of seatbelt use was lower in the serious group than in the non-serious group (p=.008). The median crush extent (seventh column of the CDC code) was higher in the serious group than in the non-serious group (p<.001). Emergency room data showed that the rates of intensive care unit (ICU) admission and death were higher among patients with serious injuries (p<.001). Similarly, the general ward/ICU admission data showed that the transfer and death rates were higher in patients with serious injuries (p<.001). The median ISS was higher in the serious group than in the non-serious group (p<.001). A predictive model was derived based on sex, age, vehicle type, seating row, belt status, collision type, and crush extent. This predictive model had an explanatory power of 67.2% for serious chest injuries. The model was estimated for external validation using the confusion matrix by applying the predictive model to the 2019 and 2020 data of the same structure as the data at the time of model development in the KIDAS database. CONCLUSIONS: Although this study had a major limitation in that the explanatory power of the predictive model was weak due to the small number of samples and many exclusion conditions, it was meaningful in that it suggested a model that could predict serious chest injuries in motor vehicle occupants (MVOs) based on actual accident investigation data in Korea. Future studies should yield more meaningful results, for example, if the chest compression depth value is derived through the reconstruction of MVCs using accurate collision speed values, and better models can be developed to predict the relationship between these values and the occurrence of serious chest injury.

Health care utilization outcomes in patients with blunt chest wall trauma following discharge from the emergency department: A retrospective, observational data-linkage study.

BACKGROUND: Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients' recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom. METHODS: This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model. RESULTS: There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33-1.99; p < 0.001; OR, 1.28; 95% CI, 1.14-1.43; p < 0.001; OR, 1.02; 95% CI, 1.01-1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes. CONCLUSION: The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Analysis of injury mechanism and thoracic response of elderly, small female PMHS in near-side impact scenarios.

OBJECTIVE: In 2020, 17% of all crash fatalities were individuals aged 65 years or older. Crash data also revealed that for older occupants, thoracic related injuries are among the leading causes of fatality. Historically, the majority of near-side impact postmortem human subjects (PMHS) studies used a generic load wall to capture external loads that were applied to PMHS. While these data were helpful in documenting biofidelity, they did not represent a realistic response an occupant would undergo in a near-side crash. The objective of this research was to test small, elderly female PMHS in a repeatable, realistic near-side impact crash scenario to investigate current injury criteria as they relate to this vulnerable population. METHOD: Ten small, elderly PMHS were subjected to a realistic near-side impact loading condition. The PMHS were targeted to be elderly females age 60+, approximately 5th percentile in height and weight, with osteopenic areal bone mineral density. Each subject was seated on a mass-production seat, equipped with a side airbag and standard three-point restraint with a pretensioner. Other boundary conditions included an intruding driver's side door. PMHS instrumentation included strain gages on ribs 3-10 bilaterally to identify fracture timing. Two chestbands were used to measure chest deflection, one at the level of the axilla and one at the level of the xiphoid process. RESULTS: Injuries observed included rib fractures, particularly on the struck side, and in multiple cases a flail chest was observed. Eight of ten subjects resulted in AIS3+ thoracic injuries, despite previously tested ATDs predicting less than a 10% chance of AIS3+ injury. Subjects crossed the threshold for AIS3 injury in the range of only 1% - 9% chest compression. Additionally, mechanisms of injury varied, as some injuries were incurred by door interactions while others came during airbag interactions. CONCLUSIONS: This research points to two areas of concern that likely require further analysis: (1) the appropriateness of potentially oversimplified PMHS testing to establish injury thresholds and define injury criteria for complicated crash scenarios; (2) the importance of identifying the precise timing of injuries to better understand the effect of current passive restraint systems.

[Bilateral thoracic trauma-"double the trouble"?] / Beidseitiges Thoraxtrauma ­ "double the trouble"?

BACKGROUND: Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma. OBJECTIVE: The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two. MATERIAL AND METHODS: In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome. RESULTS: A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors. CONCLUSION: Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions.

OBJECTIVE: This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database. METHODS: This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group. RESULTS: The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk. CONCLUSIONS: The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU.

BACKGROUND: Up to 25% of trauma deaths are related to thoracic injuries. OBJECTIVE: The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window. DESIGN: Retrospective observational analysis. SETTING: TraumaRegister DGU. PATIENTS: Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related. MAIN OUTCOME MEASURES: Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death. RESULTS: Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n  = 24 332) mortality was 5.9% ( n  = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission. CONCLUSION: About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths. TRIAL REGISTRATION: The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.

Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand.

INTRODUCTION: Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ. METHODS: A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported. RESULTS: 12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study. CONCLUSION: This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.

Relationship of Obesity and Severe Penetrating Thoracic and Abdominal Injuries in Adolescent Patients.

BACKGROUND: Over 20% of United States adolescents are obese. A thicker layer of subcutaneous adiposity might provide a protective "armor" layer against penetrating wounds. We hypothesized that adolescents with obesity presenting after isolated thoracic and abdominal penetrating trauma have lower rates of severe injury and mortality than adolescents without obesity. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for patients between 12 and 17 years old presenting with knife or gunshot wounds. Patients with body mass index (BMI) ≥30 (obese) were compared to patients with BMI <30. Sub-analyses were performed for adolescents with isolated abdominal trauma and isolated thoracic trauma. Severe injury was defined as an abbreviated injury scale grade >3. Bivariate analyses were performed. RESULTS: 12,181 patients were identified; 1603 (13.2%) had obesity. In isolated abdominal gunshot or knife wounds, rates of severe intra-abdominal injuries and mortality were similar (all P > .05) between groups. In isolated thoracic gunshot wounds, adolescents with obesity had a lower rate of severe thoracic injury (5.1% vs 13.4%, P = .005) but statistically similar mortality (2.2% vs 6.3%, P = .053) compared to adolescents without obesity. In isolated thoracic knife wounds, rates of severe thoracic injuries and mortality were similar (all P > .05) between groups. DISCUSSION: Adolescent trauma patients with and without obesity presenting after isolated abdominal or thoracic knife wounds had similar rates of severe injury, operative intervention, and mortality. However, adolescents with obesity presenting after an isolated thoracic gunshot wound had a lower rate of severe injury. This may impact the future work-up and management of adolescents sustaining isolated thoracic gunshot wounds.

A random forest model using flow cytometry data identifies pulmonary infection after thoracic injury.

BACKGROUND: Thoracic injury can cause impairment of lung function leading to respiratory complications such as pneumonia (PNA). There is increasing evidence that central memory T cells of the adaptive immune system play a key role in pulmonary immunity. We sought to explore whether assessment of cell phenotypes using flow cytometry (FCM) could be used to identify pulmonary infection after thoracic trauma. METHODS: We prospectively studied trauma patients with thoracic injuries who survived >48 hours at a Level 1 trauma center from 2014 to 2020. Clinical and FCM data from serum samples collected within 24 hours of admission were considered as potential variables. Random forest and logistic regression models were developed to estimate the risk of hospital-acquired and ventilator-associated PNA. Variables were selected using backwards elimination, and models were internally validated with leave-one-out. RESULTS: Seventy patients with thoracic injuries were included (median age, 35 years [interquartile range (IQR), 25.25-51 years]; 62.9% [44 of 70] male, 61.4% [42 of 70] blunt trauma). The most common injuries included rib fractures (52 of 70 [74.3%]) and pulmonary contusions (26 of 70 [37%]). The incidence of PNA was 14 of 70 (20%). Median Injury Severity Score was similar for patients with and without PNA (30.5 [IQR, 22.6-39.3] vs. 26.5 [IQR, 21.6-33.3]). The final random forest model selected three variables (Acute Physiology and Chronic Health Evaluation score, highest pulse rate in first 24 hours, and frequency of CD4 + central memory cells) that identified PNA with an area under the curve of 0.93, sensitivity of 0.91, and specificity of 0.88. A logistic regression with the same features had an area under the curve of 0.86, sensitivity of 0.76, and specificity of 0.85. CONCLUSION: Clinical and FCM data have diagnostic utility in the early identification of patients at risk of nosocomial PNA following thoracic injury. Signs of physiologic stress and lower frequency of central memory cells appear to be associated with higher rates of PNA after thoracic trauma. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level IV.

Risk factors of second ventilator-associated pneumonia in trauma patients: a retrospective cohort study.

BACKGROUND: Ventilator acquired pneumonia (VAP) is a frequent and serious complication in ICU. Second episodes of VAP are common in trauma patients and may be related to severity of underlying conditions, treatment or bacterial factors of the first VAP. The aim of this study was to identify risk factors of second VAP episodes in trauma injured patients (defined as the development of a new pulmonary infection during or remotely following the first episode). DESIGN: This is a single-center, retrospective cohort study of trauma injured patients who underwent a first episode of VAP between January 1, 2013 and December 31, 2020 at Beaujon Hospital. RESULTS: A total of 533 patients with a first episode of VAP were analyzed, mostly with head and/or thoracic traumatic injury. A second episode of VAP occurred in one hundred sixty-seven patients (31.3%). The main risk factors found was the degree of hypoxemia at the time of the first episode [PaO2/FiO2 ratio 100-200, OR 3.12 (1.77-5.69); < 100, OR 5.80 (2.70-12.8)] and severe traumatic brain injury characterized by an initial GCS ≤ 8 [OR 1.65 (1.01-2.74)]. CONCLUSION: Depth of hypoxemia during the first VAP episode and severity of the initial brain injury are the main risk factors for VAP second episode in trauma injured patients.

[Injury severity and injury patterns in older participants in road traffic]. / Verletzungsschwere und Verletzungsmuster bei älteren Verkehrsteilnehmern im Straßenverkehr.

Older people are or remain increasingly mobile for longer and participate in road traffic as car drivers or passengers, cyclists, and pedestrians. Regardless of their role in causing accidents, they are more likely to be seriously injured due to their higher vulnerability. If they are involved in an accident they suffer increasingly more from severe injuries, which consequently leads to longer hospitalization times. These aspects are even more applicable for persons aged 75 years or more than for persons aged 65-74 years. From a German in-depth accident study (GIDAS) analysis of the individual injuries of different types of road users, the most frequently severely injured body regions as well as the leading injuries can be derived. Primarily head and thorax injuries are of importance and secondarily also injuries to the lower extremities (especially for cyclists and pedestrians). The majority of the presented results confirm findings from comparable studies; however, this study was conducted for the first time on the basis of the abbreviated injury scale (AIS) 2015 and some individual injuries (especially commotio cerebri, which dominates in almost all age and road user groups) were upgraded from AIS1 to AIS2 in the latest AIS revision. As a result, the current results partly show significant increases in injury severity, especially for the head, compared to earlier studies based on the AIS 2008.

Characteristics of rib fracture patients who require chest computed tomography in the emergency department.

BACKGROUND: The disadvantages and complications of computed tomography (CT) can be minimized if CT is performed in rib fracture patients with high probability of intra-thoracic and intra-abdominal injuries and CT is omitted in rib fracture patients with low probability of intra-thoracic and intra-abdominal injuries. This study aimed to evaluate the factors that can identify patients with rib fractures with intra-thoracic and intra-abdominal injuries in the emergency department among patients with rib fracture. METHODS: This retrospective observational study included adult patients (age ≥ 18 years) diagnosed with rib fracture on chest radiography prior to chest CT due to blunt chest trauma in the emergency department who underwent chest CT from January 2016 to February 2021. The primary outcomes were intra-thoracic and intra-abdominal injuries that could be identified on a chest CT. Multivariate logistic regression analysis was performed. RESULTS: Among the characteristics of rib fractures, the number of rib fractures was greater (5.0 [3.0-7.0] vs. 2.0 [1.0-3.0], p < 0.001), bilateral rib fractures were frequent (56 [20.1%] vs. 12 [9.8%], p = 0.018), and lateral and posterior rib fracture was more frequent (lateral rib fracture: 160 [57.3%] vs. 25 [20.5%], p < 0.001; posterior rib fracture: 129 [46.2%] vs. 21 [17.2%], p < 0.001), and displacement was more frequent (99 [35.5%] vs. 6 [6.6%], p < 0.001) in the group with intra-thoracic and intra-abdominal injuries than in the group with no injury. The number of rib fractures (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.16-1.78; p = 0.001), lateral rib fracture (aOR, 2.80; 95% CI, 1.32-5.95; p = 0.008), and posterior rib fracture (aOR, 3.18; 95% CI, 1.45-6.94; p = 0.004) were independently associated with intra-thoracic and intra-abdominal injuries. The optimal cut-off for the number of rib fractures on the outcome was three. The number of rib fractures ≥ 3 (aOR, 3.01; 95% CI, 1.35-6.71; p = 0.007) was independently associated with intra-thoracic and intra-abdominal injuries. CONCLUSION: In patients with rib fractures due to blunt trauma, those with lateral or posterior rib fractures, those with ≥ 3 rib fractures, and those requiring O2 supplementation require chest CT to identify significant intra-thoracic and intra-abdominal injuries in the emergency department.