Value of NEXUS chest rules in assessment of traumatic chest injuries; a systematic review and a meta-analysis.

BACKGROUND: Although many studies have evaluated the diagnostic value of the National Emergency X-ray Utilization Studies (NEXUS) chest rules in assessment of traumatic chest injuries, there still is no consensus on this subject matter. Therefore, this systematic review and meta-analysis aims to review the current existing literature in order to evaluate the diagnostic value of NEXUS chest rules for assessment of traumatic chest injuries. METHOD: Databases of Medline, Embase, Scopus and Web of Science were searched until August 20th, 2022. Two independent reviewers screened the articles related to the diagnostic value of NEXUS chest radiography, NEXUS chest CT-all and NEXUS chest-Major. RESULTS: Data of 6 studies, on 23,741 patients, were included in this review. Since only one article assessed the value of NEXUS chest CT scan, the meta-analysis was performed only on NEXUS chest radiography rule. Pooled analysis on the results of 5 articles showed that the AUC of NEXUS chest radiography rule in assessment of traumatic chest injuries was 0.98 (95% CI: 0.96 to 0.99), with a sensitivity and specificity of 0.99 (95% CI: 0.98 to 0.99) and 0.32 (95% CI: 0.17 to 0.52), respectively. Positive and negative likelihood ratio of NEXUS chest radiography rule were 1.46 (95% CI: 1.12 to 1.90) and 0.04 (95% CI: 0.03 to 0.06). Overall diagnostic odds ratio was calculated to be 36.67 (95% CI: 19.17 to 70.16). CONCLUSION: Our findings indicate that NEXUS chest radiography rule is a sensitive decision rule for assessment of traumatic chest injuries, but its specificity was found to be low. However, few articles have investigated the diagnostic value of NEXUS chest rules, especially the NEXUS chest CT scan, and more studies need to be done in order to strengthen the currently provided results.

Imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV).

PURPOSE: To recognize the imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV). MATERIALS AND METHODS: A retrospective radiological review of 688 patients self-reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 30 patients with 89 thoracic injuries. Imaging and demographic data were collected. RESULTS: Thirty survivors with 89 injuries to the thorax were identified with a median age of 43.5 years (21-65 years). IPV was reported or disclosed as the direct cause of injury in 50% (15/30) of survivors, including all nine patients who sustained penetrating injuries. The most common injury type was fracture (72%, 64/89) with 52 rib, 3 sternal, 2 clavicular, and 7 vertebral fractures. There were 3 acromioclavicular dislocations. Among rib fractures, right lower anterior rib fractures (9-12 ribs) were the most common(30%, 16/52). There were 10 superficial soft tissue injuries. There were 12 deep tissue injuries which included 2 lung contusions, 2 pneumomediastinum, 7 pneumothoraces, 1 hemothorax. One third of patients had concomitant injuries of other organ systems, most commonly to the head and face, followed by extremities and one third of patients had metachronous injuries. CONCLUSION: Acute rib fractures with concomitant injuries to the head, neck, face, and extremities with an unclear mechanism of injury should prompt the radiologist to discuss the possibility of IPV with the ordering physician. ADVANCES IN KNOWLEDGE: Recognizing common injuries to the thorax will prompt the radiologists to suspect IPV and discuss it with the clinicians.

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries.

PURPOSE: To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries. METHODS: With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches. RESULTS: Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury. CONCLUSIONS: Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

The Association Between the Duration of Chest Compression and Thoracic Injuries in Patients With Non-Traumatic Out-of-Hospital Cardiac Arrest.

BACKGROUND: Current guidelines emphasize the indispensability of high-quality chest compression for improving survival in patients who experience out-of-hospital cardiac arrest (OHCA). However, chest compression can cause thoracic injuries that may contribute to poor prognosis; therefore, the purpose of this study is to identify the predictors of thoracic injuries and evaluate the association between thoracic injuries and prognosis.Methods and Results: Between June 2017 to July 2019, Utstein-style data on 384 consecutive adult patients who experienced non-traumatic OHCA and who were transferred to our hospital (Aso Iizuka Hospital) were collected. Each patient underwent a full-body computed tomography scan. Two-hundred and thirty-four patients (76%) had thoracic injuries (Group-T). The duration of chest compression was significantly longer in Group-T than in patients without thoracic injuries (Group-N; 43 vs. 32 min, respectively, P<0.001). Multivariate analysis revealed that older age and longer chest compression duration were predictors of thoracic injuries (odds ratios 1.03 and 1.07, respectively, P≤0.005). Among patients who achieved return of spontaneous circulation, Kaplan-Meier curves showed a significantly higher cumulative survival rate in Group-N than in Group-T at the 30-day follow up (log-rank test P=0.009). CONCLUSIONS: Older age and longer chest compression duration were independent predictors of thoracic injuries due to chest compression in patients who experienced non-traumatic OHCA. Moreover, the presence of thoracic injuries was associated with worse short-term prognosis.

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.

OBJECTIVE: The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children. METHODS: Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted. RESULTS: A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported. CONCLUSION: Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Clinical evaluation of AI software for rib fracture detection and its impact on junior radiologist performance.

BACKGROUND: The detection of rib fractures (RFs) on computed tomography (CT) images is time-consuming and susceptible to missed diagnosis. An automated artificial intelligence (AI) detection system may be helpful to improve the diagnostic efficiency for junior radiologists. PURPOSE: To compare the diagnostic performance of junior radiologists with and without AI software for RF detection on chest CT images. MATERIALS AND METHODS: Six junior radiologists from three institutions interpreted 393 CT images of patients with acute chest trauma, with and without AI software. The CT images were randomly split into two sets at each institution, with each set assigned to a different radiologist First, the detection of all fractures (AFs), including displaced fractures (DFs), non-displaced fractures and buckle fractures, was analyzed. Next, the DFs were selected for analysis. The sensitivity and specificity of the radiologist-only and radiologist-AI groups at the patient level were set as primary endpoints, and secondary endpoints were at the rib and lesion level. RESULTS: Regarding AFs, the sensitivity difference between the radiologist-AI group and the radiologist-only group were significant at different levels (patient-level: 26.20%; rib-level: 22.18%; lesion-level: 23.74%; P < 0.001). Regarding DFs, the sensitivity difference was 16.67%, 14.19%, and 16.16% at the patient, rib, and lesion levels, respectively (P < 0.001). No significant difference was found in the specificity between the two groups for AFs and DFs at the patient and rib levels (P > 0.05). CONCLUSION: AI software improved the sensitivity of RF detection on CT images for junior radiologists and reduced the reading time by approximately 1 min per patient without decreasing the specificity.

Concomitant injuries in patients with thoracic vertebral body fractures-a systematic literature review.

PURPOSE: The aim of this study was to give a systematic overview over the rate and location of concomitant injuries, the probability of suffering from neurological deficits, and to give evidence of the timing of surgery in severely injured patients with unstable thoracic vertebral body fractures. METHODS: This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to November 2020 dealing with unstable fractures of the mid-thoracic spine. RESULTS: Altogether, 1109 articles were retrieved from the literature search. A total of 1095 articles were excluded. Thus, 16 remaining original articles were included in this systematic review depicting the topics timing of surgery in polytraumatized patients, outcome neurologic deficits, and impact of concomitant injuries. The overall level of evidence of the vast majority of studies is low. CONCLUSION: The evidence of the available literature is low. The cited studies reveal that thoracic spinal fractures are associated with a high number of neurological deficits and concomitant injuries, particularly of the thoracic cage and the lung. Thereby, diagnostic algorithm should include computer tomography of the whole thoracic cage if there is any clinical sign of concomitant injuries. Patients with incomplete neurologic deficits benefit from early surgery consisting of decompression and long-segmental stabilization.

Radiomics score predicts acute respiratory distress syndrome based on the initial CT scan after trauma.

OBJECTIVES: Acute respiratory distress syndrome (ARDS) constitutes a major factor determining the clinical outcome in polytraumatized patients. Early prediction of ARDS is crucial for timely supportive therapy to reduce morbidity and mortality. The objective of this study was to develop and test a machine learning-based method for the early prediction of ARDS derived from the first computed tomography scan of polytraumatized patients after admission to the hospital. MATERIALS AND METHODS: One hundred twenty-three patients (86 male and 37 female, age 41.2 ± 16.4) with an injury severity score (ISS) of 16 or higher (31.9 ± 10.9) were prospectively included and received a CT scan within 1 h after the accident. The lungs, including air pockets and pleural effusions, were automatically segmented using a deep learning-based algorithm. Subsequently, we extracted radiomics features from within the lung and trained an ensemble of gradient boosted trees (GBT) to predict future ARDS. RESULTS: Cross-validated ARDS prediction resulted in an area under the curve (AUC) of 0.79 for the radiomics score compared to 0.66 for ISS, and 0.68 for the abbreviated injury score of the thorax (AIS-thorax). Prediction using the radiomics score yielded an f1-score of 0.70 compared to 0.53 for ISS and 0.57 for AIS-thorax. The radiomics score achieved a sensitivity and specificity of 0.80 and 0.76. CONCLUSIONS: This study proposes a radiomics-based algorithm for the prediction of ARDS in polytraumatized patients at the time of admission to hospital with an accuracy that competes and surpasses conventional scores despite the heterogeneous, and therefore more realistic, scanning protocols. KEY POINTS: • Early prediction of acute respiratory distress syndrome in polytraumatized patients is possible, even when using heterogenous data. • Radiomics-based prediction resulted in an area under the curve of 0.79 compared to 0.66 for the injury severity score, and 0.68 for the abbreviated injury score of the thorax. • Highlighting the most relevant lung regions for prediction facilitates the understanding of machine learning-based prediction.

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study.

BACKGROUND: The impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI. METHODS: A retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications. RESULTS: A total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00-2.54 and OR 1.33, 95% CI: 1.06-1.68, respectively). CONCLUSION: CWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates.

[Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]. / Indikation, Prozedere und Outcome der präklinischen Notfallthorakotomie ­ eine systematische Literaturrecherche.

BACKGROUND: Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. METHOD: A systematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint. RESULTS: A total of 4616 publications were found of which 21 publications with a total of 287 patients could be included in the analyses. For a detailed descriptive analysis, 15 publications with a total of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS). CONCLUSION: The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.

Characteristics and outcome of traumatic chest injury patients visited a specialized hospital in Addis Ababa, Ethiopia: A one-year retrospective study.

PURPOSE: Injury continues to be an important cause of morbidity and mortality in both developed and developing countries. Globally, it is responsible for approximately 5.8 million deaths per year and 91% of these deaths occur in developing countries. Road traffic collision, suicides and homicides are the leading cause of traumatic deaths. Despite the fact that traumatic chest injury is being responsible for 10% of all trauma-related hospital admissions and 25% of trauma-related deaths across the world including in Ethiopia, only few published studies showed the burden of traumatic chest injury in Ethiopia. So, this study aims at assessing the characteristics and outcome of traumatic chest injury patients visited Tikur Anbesa Specialized Hospital (TASH) over one year period. METHODS: A single center based retrospective study was done. We collected data from patients' records to assess characteristics and outcome of traumatic chest injury at TASH over one year period. All patients diagnosed with traumatic chest injury and received treatment at the hospital from January 1 to December 31, 2016 regardless of its types and severity levels were included in the study. Patients with incomplete medical records for at least 20% of the study variables and without detailed medical history, or patients died before receiving any health care were excluded from the study. The collected data were cleaned and entered into Epidata version 3.1 and exported to SPSS Version 21.0 for analysis. Bivariate and multivariate logistic regression models were used to examine factors associated with outcome of traumatic chest injury patients. RESULTS: A total of 192 chest injury patients were included in the study and about one-fourth of chest injury victims were died during treatment period in TASH. Road traffic collision (RTC) was the leading cause of morbidity and mortality among traumatic chest injury victims. Age of the victims (adjusted odds ratio (AOR) 8.9, 95% confidence interval (CI) 1.51-53.24), time elapsed between the occurrence of traumatic chest injury and admission to health care facilities (AOR 4.6, 95% CI 1.19-18.00), length of stay in hospital (AOR 0.12, 95% CI 0.02-0.58), presence of multiple extra-thoracic injury (AOR 25, 95% CI 4.18-150.02) and development of complications (AOR 23, 95% CI 10-550) were factors associated with death among traumatic chest injury patients in this study. CONCLUSION: RTC contributed for a considerable number of traumatic chest injuries in this study. Old age, delay in delivering the victim to health care facilities, length of stay in hospital, and development of atelectasis and pneumonia were associated with death among traumatic chest injury patients. Road safety interventions, establishment of organized pre-hospital services, and early recognition and prompt management of traumatic chest injury related complications are urgently needed to overcome the underlying problems in the study setting.

Clinical predictors of abnormal chest CT scan findings following blunt chest trauma: A cross-sectional study.

PURPOSE: Some surgeons believe that chest computed tomography (CT) scan should be used more prudently in management of blunt chest trauma patients. This study aimed to evaluate the clinical predictors of abnormal chest CT scan findings in trauma patients. METHODS: This cross-sectional study was conducted on blunt chest trauma patients aged ≥18 years who were referred to the emergency departments of two educational hospitals and underwent chest CT scan. These patients were enrolled in the study using a non-probability sampling method. The exclusion criteria included: class III or IV hemodynamic shock, need for immediate surgical or neurosurgical interventions, penetrating trauma, lack of required information, and pregnancy. Demographic factors, accident details, trauma mechanism, vital signs, and level of consciousness in predicting abnormal chest CT scan findings were evaluated. Analysis was performed using IBM SPSS statistics 21. RESULTS: A total of 977 patients (male 51.5%, female 48.5%) with the mean age of (41.71 ± 14.24) years, range 18-88 years were studied; 34.2% of them with high energy trauma mechanism. With 334 (34.2%) patients had abnormal findings on chest X-ray (CXR) and 332 (34.0%) cases had an abnormal findings on chest CT scan (agreement rate was 99.4%). There was a significant correlation between male gender (p < 0.0001), GCS<15 (p < 0.0001), high energy trauma mechanism (p < 0.0001), unstable hemodynamics (p < 0.01), and clinical signs and symptoms (p < 0.0001) with chest CT findings. Chest wall deformity (odds = 8; p < 0.0001), generalized tenderness (odds = 6.6, p < 0.0001), and decreased cardiac sound (odds = 3.8, p < 0.0001) were the important and independent clinical predictors of abnormal chest CT scan findings. CONCLUSION: Based on the findings, chest wall deformity, generalized tenderness, decreased cardiac sound, distracting pain, chest wall tenderness, high energy trauma mechanism, male gender, respiratory rate > 20 breathes/min, decreased pulmonary sound, and chest wall crepitation were independent clinical predictors of abnormal chest CT scan findings following blunt trauma.

Utilization of chest CT for injured patients during visits to U.S. emergency departments: 2012-2015.

INTRODUCTION: Increased use of computed tomography (CT) during injury-related Emergency Department (ED) visits has been reported, despite increased awareness of CT radiation exposure risks. We investigated national trends in the use of chest CT during injury-related ED visits between 2012 and 2015. METHODS: Analyzing injury-related ED visits from the 2012-2015 United States (U.S.) National Hospital Ambulatory Medical Care Survey (NHAMCS), we determined the percentage of visits that had a chest CT and the diagnostic yield of these chest CTs for clinically-significant findings. We used survey-weighted multivariable logistic regression to determine which patient and visit characteristics were associated with chest CT use. RESULTS: Injury-related visits accounted for 30% of the 135 million yearly ED visits represented in NHAMCS. Of these visits, 817,480 (2%) received a chest CT over the study period. The diagnostic yield was 3.88%. Chest CT utilization did not change significantly from a rate of 1.73% in 2012 to a rate of 2.31% in 2015 (p = 0.14). Multivariate logistic regression demonstrated increased odds of chest CT for patients seen by residents versus by attendings (adjusted odds ratio [AOR] 2.08, 95% confidence interval [CI] 1.41-3.08). Patients aged 18-59 and 60+ had higher AORs (5.75, CI 3.44-9.61 and 9.81, CI 5.90-16.33, respectively) than those <18 years of receiving chest CT. CONCLUSIONS: Overall chest CT utilization showed an increased trend from 2012 to 2015, but the results were not statistically significant.

Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study.

BACKGROUND: Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. AIM: To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. METHODS: 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. RESULTS: One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term 'care bundle' (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. CONCLUSIONS: Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway.

EPIDURAL ANALGESIA IN MULTIPY INJURED PATIENTS WITH SEVERE CHEST TRAUMA: TWO CASE REPORTS AND LITERATURE REVIEW.

Multiply injured patients with severe chest trauma have different combinations of associated extra thoracic injuries making their treatment complex. Severe pain is a prominent symptom in a vast majority of severe chest injuries and causes deterioration of respiratory function. Epidural analgesia provides efficient pain relief but its use in this group of patients is burdened with complications, contraindications and technical difficulties. We present two cases in which epidural analgesia was successfully used in polytrauma patients with severe chest injuries and hypoxemic respiratory failure, and discuss advantages, possible pitfalls and complications.

[Thoracic and abdominal injuries caused by air weapons]. / Pulevye raneniia grudi i zhivota iz pnevmaticheskogo oruzhiia.

Thoracic and abdominal injuries caused air weapons are rarer compared with gunshot wounds. Nevertheless, pneumatic weapons are able to inflict potentially fatal lesions despite small mass and dimension of projectile. Three clinical cases of patients with various internal injuries are presented in the article. Differentiated diagnostic and surgical approach is suggested.

Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests.

BACKGROUND: We aimed to determine the incidence of and associated risk factors for cardiopulmonary resuscitation (CPR)-related injuries in non-survivors of out-of-hospital cardiac arrests (OHCAs) in an emergency medical service (EMS) system in which all CPR procedures are performed on scene and patients are not routinely transported to the hospital with ongoing CPR. MATERIAL AND METHODS: We conducted this prospective observational study between 1 June 2013, and 31 May 2014. Data were collected from EMS datasheets and forensic autopsy records. The exclusion criteria were OHCAs due to trauma in the thoracic or abdominal area. EMS adhered to the European Resuscitation Council Resuscitation Guidelines (2010) during the resuscitation attempts. RESULTS: Emergency medical service provided CPR in 280 attended OHCAs with 207 cases terminated on scene. A total of 149 patients underwent a forensic autopsy and 47% had a CPR-related injury. The most common injuries were multiple rib fractures (43%), with 22% of patients having more than eight fractured ribs. Abdominal visceral injuries or injuries related to airway management were rare. The injuries were associated with older age, male gender, initial shockable rhythm and public location of the cardiac arrest (P < .05 respectively). In the multivariable regression analysis, older age, male gender, and public location were independent predictors for injuries. There were no differences in the durations of the CPR attempt between the injured and non-injured groups. CONCLUSION: Older age, male gender, and public location were independently associated with CPR-related injuries. The duration of the resuscitation attempts did not affect the incident of injuries.

Longest delayed hemothorax reported after blunt chest injury.

INTRODUCTION: Blunt chest injury is a common presentation to the emergency department. However, a delayed hemothorax after blunt trauma is rare; current literature reports a delay of up to 30days. We present a case of 44-day delay in hemothorax which has not been previously reported in current literature. CASE REPORT: A 52-year-old Caucasian male first presented to the emergency department complaining of persistent right sided chest pain 2weeks after having slipped on a wet surface at home. His initial chest X-ray showed fractures of the right 7th and 8th ribs without a hemothorax or pneumothorax. He returned 30days after the initial consultation (44days post-trauma) having increasing shortness of breath. A chest X-ray this time revealed a large right hemothorax and 1850ml of blood drained from his chest. There was a complete resolution of the hemothorax within 48h and the patient was discharged after a 6-week follow-up with the chest physicians. DISCUSSION: Delayed hemothorax after blunt trauma is a rare clinical occurrence but associated with significant morbidity and mortality. The management of delayed hemothorax includes draining the hemothorax and controlling the bleeding. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be vigilant and weary that hemothorax could be a possibility after a chest injury despite a delay in presentation. A knowledge of delayed hemothorax will prompt physicians in providing important advice, warning signs and information to patients after a chest injury to avoid a delay in seeking medical attention.

Pulmonary Contusion and Traumatic Pneumatoceles in a Platform Diver with Hemoptysis.

BACKGROUND: Injuries in divers resulting purely from impact with the water are uncommon in the published literature. We present a case report of pulmonary contusion in a young diver. CASE REPORT: A young, healthy competitive platform diver landed flat on his back in the water from a dive of 10 meters. He complained of upper back pain and had an episode of hemoptysis after the dive. He was initially observed for 15 hours postinjury, and was discharged when three chest radiographs (CXRs) taken at 1, 7, and 11 hours postinjury did not show significant abnormalities. Thirty-six hours postinjury, the patient experienced repeat hemoptysis and returned to the emergency department, where a fourth CXR performed 43 hours postinjury was normal. A computed tomography (CT) scan revealed pulmonary contusion and traumatic subpleural pneumatoceles. The patient was admitted to the cardiothoracic ward for observation. He recovered well with conservative treatment and was discharged on the fifth day after injury with clearance for air travel. In this patient with a high-energy mechanism of rapid deceleration and hemoptysis at the scene, there may be grounds for performing a CT scan of the thorax at the time of the first presentation, although the CT findings did not change conservative management of this patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should recognize that a dive into water may generate sufficient impact to produce a pulmonary contusion. If the patient is clinically well and the CXR results are normal, the decision to initiate a CT scan and subsequent disposition may be based on clinical judgement and institutional practice.

Isolated costal cartilage fractures: the radiographically overlooked injuries.

Isolated costal cartilage fractures are benign and rare. A 65-year-old man had a sustained chest pain after a fist punch in the past month. A 3-dimensional computed tomography revealed left 7th and 8th costal cartilage fractures with fracture dislocations. As he refused an open fracture reduction, he was advised to have a rest with subsequent follow-up. Ultrasound screening is recommended in patients with sustained posttraumatic chest pains in order to rule out possible costal cartilage fractures. The therapeutic regimen generally depends on the location and severity of the fracture.