Surgical Rib Fixation is Associated With Lower Mortality in Patients With Traumatic Rib Fractures.

INTRODUCTION: Nonoperative management (NOM) along with supportive care has been the adopted approach for traumatic rib fractures; however, surgical approaches have emerged recently to treat this common pathology. Despite this, there are no guidelines for surgical rib fixation in patients with traumatic rib fractures. METHODS: An institutional review board-approved retrospective cohort study was performed at the Puerto Rico Trauma Hospital aiming to compare the outcomes and complications between patients with traumatic rib fractures who undergo surgical fixation and their counterparts with NOM. The study period comprised from January 2016 through July 2020. Outcomes were evaluated with negative binomial and logistic regressions. RESULTS: Fifty patients were identified for the surgical rib fixation group, who were matched to 150 patients who received NOM. The majority of patients were male (91.5%), with a median (interquartile range) age of 53 (29) years. Concomitant chest injuries were significantly more prevalent in the operative group, such as flail segment (P < 0.001), number of fractures (P < 0.001), and displaced rib fractures (P < 0.001). Although hospital length of stay was 25% (95% confidence interval: 1.02-1.54) longer in the surgical group, this intervention was associated with an 85% (95% confidence interval: 0.03-0.70) lower mortality rate when compared to conservative management. CONCLUSIONS: Rib fixation may offer some benefits in selected patients with traumatic rib fractures, such as those with bilateral rib fractures, multiple displaced rib fractures, flail segment, and concomitant thoracic injuries. This study may serve as a guide for treatment strategy and patient selection regarding the surgical management of traumatic rib fractures.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

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.

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.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.

OBJECTIVES: Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax. METHODS: Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis. RESULTS: A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax. CONCLUSIONS: Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department.

INTRODUCTION: Proper pain in acute scapular fractures can be challenging to achieve due to their anatomy and location. While the current mainstay of treatment relies on opioids, the Rhomboid Intercostal Block (RIB) has been utilized for anesthesia to effectively treat pain for scapular fractures. However, it has not yet been utilized in the emergency department (ED). CASE REPORT: In this case report, we present the first documented use of RIB to treat pain safely and effectively in a 69-year-old male with a scapula fracture following a ground-level fall in the ED. The RIB was performed under ultrasound guidance, providing precise localization and administration of the nerve block. CONCLUSION: The RIB demonstrated successful pain management in the ED. Although hopeful, further research is needed to understand limitations, potential side effects, length of pain control, and overall clinical outcomes of the RIB in the ED.

Earthquake-related isolated blunt thoracic trauma patients: A special population study in the emergency department.

OBJECTIVE: The objective of this study is to compare patients with severe and mild blunt thoracic trauma, who survived an earthquake and presented to the emergency department (ED), in order to identify factors influencing the severity of trauma in earthquake-related thoracic injuries. METHODS: This retrospective, cross-sectional, observational comparative study included patients with isolated thoracic injuries due to the February 6th Kahramanmaras earthquake. The patients were categorized into severe and mild groups based on chest trauma scoring (CTS), and their characteristics were compared. RESULTS: The study included 53 patients, with 43 (88.1%) classified as having mild thoracic trauma and 10 (18.9%) classified as having severe thoracic trauma. There was no significant difference in the duration of entrapment between the groups (p = 0.824). The incidence of hemothorax, pneumothorax, rib fractures, and pneumomediastinum did not differ significantly between the two groups (p > 0.05). However, severe thoracic trauma was associated with a higher rate of lung contusion compared to the mild group (p = 0.045). The severe group exhibited significantly higher median scores for lung contusion, rib fractures, and total CTS compared to the mild group (p < 0.001). The mortality rate was significantly higher in the severe group (40%, n = 4) compared to the mild group (2.3%, n = 1) (p = 0.003). CONCLUSION: The duration of entrapment did not significantly affect the severity of thoracic injuries in earthquake-related blunt thoracic trauma. However, lung contusion was found to be a more prominent feature in these injuries compared to other clinical conditions such as hemothorax and pneumothorax. These findings highlight the distinct clinical implications of earthquake-related thoracic trauma and may have implications for management strategies in these cases.

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma.

OBJECTIVE: To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine. MATERIALS AND METHODS: In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed. RESULTS: 100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age. CONCLUSION: Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review.

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

[Surgical Therapy of Slipping Rib Syndrome].

We have operated on two cases of slipped ribs syndrome( SRS). Both patients were men in their 40s with a history of right thoracic trauma who were referred to us because of unexplained lower thoracic pain. The left rib was positive for hooking maneuver (lift test), and dynamic ultrasonography showed narrowing of the intercostal space, which led to the diagnosis of SRS. in the first case, the tip of the ninth rib cartilage was excised, and the ninth and tenth rib cartilages were sutured and fixed with No.2 fiber wire in two places with Z sutures. In the second case, the tip of the ninth rib cartilage was excised, the eighth and ninth ribs and the ninth and tenth ribs were fixed with No.2 fiber wire with Z sutures as in the first case, and a 0.7 mm thick poly-L-lactide (PLLA) plate was added between the eighth and tenth rib cartilages. In both cases, the postoperative course was good and the pain disappeared. SRS should be recognized as a disease and surgical treatment should be used as therapy.

[Management of Tracheobronchial Injuries due to Brunt Trauma].

BACKGROUND: Tracheobronchial injuries resulting from blunt trauma are relatively rare among chest injuries. However, if these injuries are not managed properly, they can be fatal. The prognosis is intricately linked to the precise diagnosis and treatment. We herein report three cases of tracheobronchial trauma that required surgical intervention. Case 1:A 17-year-old male sustained injuries when his torso became entangled in heavy machinery. The diagnosis revealed a tear in the right main bronchus, which required transportation with left single- lung ventilation. The patient was treated by tracheobronchial reconstruction. Case 2:A 71-year-old male experienced trauma when his car collided with a utility pole. He was transported to the hospital after tracheal intubation due to a laceration of the tracheal membranous area. The site of the injury was closed with sutures. Case 3:A 17-year-old female who had been struck by a train suffered acute respiratory failure and was transported to the hospital after intubation. Veno-venous extracorporeal membrane oxgenation (VV-ECMO) was initiated in response to poor oxygenation. Complete rupture of the right middle bronchial trunk and laceration of the right main bronchial membrane were observed, and bronchoplasty was performed. CONCLUSION: A swift and accurate diagnosis, coupled with timely and judicious therapeutic interventions, play a pivotal role in managing tracheal and bronchial injuries.

[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.

Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis.

INTRODUCTION: Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level. MATERIALS AND METHODS: We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI. RESULTS: A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05). CONCLUSIONS: Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.

Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial.

BACKGROUND: The benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O2) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients. METHODS: The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO2/FiO2 ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O2 and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO2/FiO2 ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS). RESULTS: Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively). CONCLUSION: A prompt association of HFNC-O2 with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure. CLINICAL TRIAL REGISTRATION: NCT03943914, Registered 7 May 2019.

Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study.

BACKGROUND: Pancreatic injury is rare, but it has a high mortality rate and its optimal treatment remains controversial. This study aimed to evaluate the clinical characteristics, management strategies, and outcomes of patients with blunt pancreatic injury. METHODS: This retrospective cohort study was performed on patients with a confirmed blunt pancreatic injury who were admitted to our hospital from March 2008 to December 2020. The clinical characteristics and outcomes of patients receiving different management strategies were compared. The risk factors for in-hospital mortality were evaluated by performing a multivariate regression analysis. RESULTS: A total of 98 patients diagnosed with blunt pancreatic injury were identified, with 40 patients having undergone nonoperative treatment (NOT) and 58 patients having undergone surgical treatment (ST). The overall in-hospital deaths were 6 (6.1%), including 2 (5.0%) and 4 (6.9%) in the NOT and ST groups, respectively. Pancreatic pseudocysts occurred in 15 (37.5%) and 3 (5.2%) of the NOT and ST groups, respectively, showing a significant difference between the two groups (P < 0.001). In the multivariate regression analysis, concomitant duodenal injury (OR = 14.42, 95% CI 1.27-163.52; P = 0.031) and sepsis (OR = 43.47, 95% CI, 4.15-455.75; P = 0.002) were independently associated with in-hospital mortality. CONCLUSIONS: Except for the higher incidence of pancreatic pseudocysts in the NOT group than in the ST group, there were no significant differences in the other clinical outcomes between the two groups. Concomitant duodenal injury and sepsis were the risk factors for in-hospital mortality.

Management of thoracic trauma.

Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces.

BACKGROUND: Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. METHODS: We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. RESULTS: Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. CONCLUSIONS: Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country.

BACKGROUND: One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY: A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS: The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION: The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.

Risk factors for thirty-day morbidity and mortality after spinal trauma.

BACKGROUND: Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined. METHODS: Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed. RESULTS: The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay. CONCLUSION: Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020.

BACKGROUND: A gunshot wound to the colon is a frequent injury in armed conflicts. An example of a high-energy modern weapon is hollow-point bullets, which is associated with increased tissue damage and lethal outcome. The aim of this study was to evaluate gunshot injuries to the colon in combat patients and to assess the difference in clinical features of patients with colon injuries by hollow-point versus shape-stable bullets. PATIENTS AND METHODS: Analyses of clinical data were performed on 374 male soldiers from the Armed Forces of Ukraine with gunshot abdominal wounds with injury to the colon in East Ukraine between 2014 and 2020. Out of 374 injured, 112 (29.9%) patients were diagnosed with penetrating gunshot bullet wounds: 69/112 (61.6%) were injured by shape-stable bullets, and the hollow-point bullets injured 43/112 (38.4%) patients. RESULTS: More severe hemorrhagic shock stages were in patients injured by hollow-point bullets: shock stages III-IV was in 25 (58.1%) patients injured by the hollow-point bullets vs. 17 (24.6%) patients injured by shape-stable bullets (p = 0.0004). Left colon parts were more frequently injured as compared to the right colon side or transverse colon: 21 (48.8%) patients were injured by the hollow-point bullets (p < 0.0001), and 41 (59.4%) patients were injured by the shape-stable bullets (p = 0.032). A significant difference was identified for the frequent injury to the middle colon within the entire cohort (p = 0.023). Patients injured by the hollow-point bullets demonstrated a higher frequency of 3-5 areas of colon gunshot defects, which was detected in 18 (41.8%) patients injured by hollow-point bullets and none with shape-stable bullets injury (p = 0.0001). Colon Injury Scale (CIS) IV was detected in 7 (16.3%) patients injured by the hollow-point bullets as compared to 2 (2.9%) patients injured by shape-stable bullets (p = 0.011). Colostomy was performed in 14 (69%) patients injured by shape-stable bullets and in 12 (27.9%) patients injured by hollow-point bullets (p > 0.05). 15 (35%) patients died after injury by the hollow-point bullet, whereas 9 (13%) patients after damage by the shape-stable bullets (p = 0.0089). CONCLUSIONS: All patients should be suspected to have an injury by bullet with expanding properties in case of penetrating abdominal injury (absent of outlet wound) and careful revision of the abdomen must be performed to identify possible multiorgan injury as well as multiple gunshot defects of the intestine.