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PubMed1977

Indications for thoracotomy following penetrating thoracic injury.

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.

Drainage↗
PubMed1989

[Characteristics of diagnosis and surgical tactics in penetrating thoracic injuries].

The penetrating thoracic injury was observed in 355 patients. Primary debridement (PD) of a wound was performed in 23, PD and closed drainage of the pleural cavity--in 33, PD with subsequent thoracotomy--in 42, thoracotomy--in 257 patients. Injury to the lung was observed in 185 patients, heart--in 46, major vessels--in 9, thoraco-abdominal--in 47. Complications occurred in 54 (15.2%) patients: in 8--continued bleeding, in 21--pneumonia, in 19--pyothorax, in 6--wound suppuration and costal osteomyelitis. Eighteen (5%) patients died: 15--from hemorrhagic shock and massive bleeding, 2--from sepsis and abscessed pneumonia, 1--from peritonitis and intraabdominal bleeding.

Adolescent↗
PubMed1998

[Blunt thoracic injury].

Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.

Accidents, Traffic↗
PubMed1991

[Thoracotomies in thoracic injuries--indications and results].

Most thoracic injuries can be treated adequately with intensive care, pleural drainage and judicious physiotherapy. From the total of 571 patients with severe thoracic injuries treated in the Surgical Department of the University of Cologne over the last 10 years, 14% of those with blunt trauma (BT) and 33% with penetrating trauma (PT) underwent thoracotomy. Thoracotomy for PT was usually performed earlier and gave better results than thoracotomy for BT. With one exception, all PT underwent thoracotomy in the first 24 h after admission. For thoracotomy carried out for BT however, 38% took place after 24 h and 21% after 5 days. Postoperative mortality for BT was 3 times higher than for PT (56% vs. 18%). Reasons for this are to be found in the severe thoracic and general injuries associated with BT. The surgical procedure will depend on the type and extent of the thoracic and general injuries and on the general condition of the patient.

Adolescent↗
PubMed2006

[Clinical features of thoracic injury; special reference to diaphragmatic injury].

UNLABELLED: We investigated the clinical feature of thoracic injury patients, mainly with diaphragmatic injury. From 1993 to 2005, 739 patients with thoracic injury were treated at our life-saving emergency center. There were more blunt trauma patients than penetrating injury patients (693 cases vs 46 cases). Regarding the thoracic injury patients, the causes of trauma were traffic injury in 462 (62.5%), unexpected accident including work place accident in 153 (20.7%), suicide in 90 (12.2%), and assault in 34 (4.6%). As the numbers of injured organs increased, the mortality rate increased. Among 156 patients with cardiopulmonary arrest on admission, 155 patients died. This result suggested that saving the life of patients presenting with cardiopulmonary arrest on admission is extremely difficult. Thirty-eight cases (5.1%) required surgical treatment, and surgery to repair diaphragmatic injury was performed in 14 cases. In 6 cases of diaphragmatic injury, thoracoscopy was performed during the examination and/or surgery. CONCLUSION: Urgently transporting thoracic injury patients to hospital before the onset of cardiopulmonary arrest is therefore essential in order to reduce the mortality rate of these patients. In addition, thoracoscopy is very useful for both examining and treating traumatic diaphragmatic injury patients.

Diaphragm↗
PubMed2003

Development of Side Impact Thoracic Injury Criteria and Their Application to the Modified ES-2 Dummy with Rib Extensions (ES-2re).

Forty-two side impact cadaver sled tests were conducted at 24 and 32 km/h impact speeds into rigid and padded walls. The post-mortem human subjects were instrumented with accelerometers on the ribs and spine and chest bands around the thorax and abdomen to characterize their mechanical response during the impact. Load cells at the wall measured the impact force at the level of the thorax, abdomen, pelvis, and lower extremities. The resulting injuries were determined through detailed autopsy and radiography. Rib fractures with or without associated hemo/pneumo thorax or flail chest were the most common injury with severity ranging from AIS=0 to 5. Full and half thorax deflections were computed from the chest band data. The cadaver test data was analyzed using ANOVA and logistic regression. The age of the subject at the time of death had influence on injury outcome while gender and mass of the subject had little or no influence on injury outcome. Existing side impact injury criteria were evaluated such as Thoracic Trauma Index (TTI), Average Spinal Acceleration (ASA), full and half thorax deflections, chest velocity and viscous criterion, and contact force. The analysis results indicate that maximum normalized average half thorax deflection was the best predictor of AIS>/=3 and AIS>/=4 thoracic injury. TTI and upper spine accelerations were also good predictors of thoracic injury. Sixteen side impact sled tests were also conducted with the modified ES-2 dummy with rib extensions (ES-2re) under similar impact conditions as the cadaver tests. The rib extensions were added to the original ES-2 dummy ribs to prevent the "seat grabbing" action of the back plate that was noticed in some side impact vehicle crash tests with the ES-2 dummy. A separate analysis was conducted using the injury response and subject characteristics from the cadaver tests and the physical parameters derived from measurements on the ES-2re dummy in sled tests under similar conditions as the cadaver tests. This analysis provided thoracic injury criteria that could be directly applied to the ES-2re dummy. This analysis indicated subject age to have significant influence on injury outcome. Maximum rib deflection and ASA of the ES-2re were the best predictors of thoracic injury. A 50% risk of AIS>/=3 thoracic injury for a 45 year old corresponds to 44 mm (standard error range: 32 to 54 mm) of ES-2re maximum rib deflection and ASA of 46 gs (standard error range: 34 -58 gs).

Journal Article↗
PubMed1990

[Characteristics of thoracic injuries in children].

Thoracic trauma is uncommon in children. It should not be managed any more as adult's trauma. We present our experience with 85 children form 1 to 16 years of age, presenting severe thoracic trauma treated in Lausanne, Switzerland, between 1976 and 1990. The specific features of diagnosis, treatment and outcome are presented. Most of them were involved in traffic accidents (62%), 55% had multisystemic injuries. The mortality rate was not a function of the Injury Seventy Score as in adults, but was only related to the Glasgow Score. Only 3 patients (3.5%) had hemodynamic instability on admission in relation with their thoracic injury. Patients with intrathoracic lesions showed dyspnoea (65%), cyanosis (25%), or clinical suspicion of a pleural effusion or a pneumothorax (47%). However 12 children had an asymptomatic severe thoracic injury. In 53 patients (62%) the auscultation was found abnormal either with absent or diminished breath sounds or other pathological findings. 10 out of 26 cases of pneumothorax could be suspected by percussion dullness. Chest X-rays showed a lesion in 76% of cases. Only 30% of the pneumothorax were associated with visible rib fractures. 10 children suffered from 4 to 12 fractures of the ribs (mean 6.6). None of these patients presented a flail chest as in adults, even when multiple rib fractures existed. 31 thoracic drainages were performed, during a mean period of 3.3 days. 30 patients were intubated and ventilated, 22 of these due to a neurosurgical condition. All patients had physiotherapy starting on day 2, under analgesia if necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Traumatic mediastinal lymphocele mimicking other thoracic injuries: case report.

Thoracic duct injury and chylothorax are rare consequences of blunt thoracic trauma. A contained mediastinal lymph collection (ie, lymphocele) is rarer still. The article describes a case of posttraumatic mediastinal widening resulting from a high-speed motor vehicle accident. During the patient's radiologic assessment aortic rupture, paraspinal hematoma, esophageal injury, mediastinal tumor, and pseudomeningocele were sought and subsequently excluded. At this point a traumatic lymphocele was suggested, and the diagnosis was confirmed by computed tomography-guided percutaneous needle aspiration. The anatomy and physiology of the thoracic duct are reviewed.

Adult↗
PubMed2002

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.

STUDY OBJECTIVE: We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. METHODS: We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. RESULTS: Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. CONCLUSION: Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.

Accidental Falls↗
PubMed1997

Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study.

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

Abbreviated Injury Scale↗
PubMed2000

Penetrating thoracic injuries: what we have learnt.

BACKGROUND: Thoracic injuries, especially cardiac, vascular, and transmediastinal injuries, are amongst the most lethal of penetrating injuries. METHOD: Our experience at Groote Schuur Hospital is reviewed, where up to 1,000 patients were admitted annually with penetrating chest wounds between 1982 and 1997. RESULTS: The approximate pre-hospital mortality was 86% with penetrating cardiac injuries, 92 % with extrapericardial vascular injuries, and 11 % with pulmonary injuries. Less than 2% of pneumothorax cases and less than 10% of haemothorax cases required surgical intervention. Thoracoscopic evacuation of retained clots was successful in the majority of the latter. Most penetrating injuries of the thoracic duct required surgical exploration. The mortality of penetrating cardiac injuries varied according to clinical presentation (moribund 52%, hypovolaemia 20% and tamponade 2-5%) and the chamber involved. Higher mortalities were associated with atrial injuries. CONCLUSIONS: The appropriate use of intercostal drains and therapeutic thoracoscopy are important considerations in penetrating non-cardiac thoracic trauma. Rapid transportation, immediate triage, open-minded use of emergency room thoracotomy, and aggressive surgical management with liberal use of sub-xiphisternal pericardial windows are important factors in improving the survival of penetrating cardiac trauma.

Drainage↗
PubMed2001

Decelerational thoracic injury.

BACKGROUND: Among the five major decelerational thoracic injuries [myocardial contusion (MC), traumatic aortic disruption (TAD), sternal fracture (SF), flail chest (FC), and tracheobronchial disruption (TBD)], coexisting injuries are seemingly rare. METHODS: To test this hypothesis, we reviewed the records of all patients, with final diagnosis (FDX) codes of these injuries, treated at our Level I trauma center for the 10 years preceding 1997. RESULTS: Among 142 patients, all victims of motor vehicle crashes, there were 38 MC, 36 TAD, 33 FC, 28 SF, and 7 TBD. There were six coexisting injuries (3.5%). Three patients with coexisting injury died in the operating room. All three had TAD; one of these three had TBD plus MC; one had additionally FC and MC and the third had FC in addition to the TAD. One patient with SF and probable MC died in the emergency room. Two patients with FC and a coexisting injury survived. One had MC, the other SF. CONCLUSION: We conclude that these decelerational thoracic injuries, with the exception of sternal fracture, are sufficiently life threatening by themselves to cause fatality. When combined, the threat to life is potentiated. Death occurs at the scene or shortly after arrival in the ER. The diagnosis of one may help exclude the diagnosis of each of the other four. The role of sternal fracture in this paradigm remains an enigma.

Accidents, Traffic↗