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PubMed1981

Intrapleural instillation of streptokinase. Effects on systemic fibrinolysis.

Ten consecutive patients aged 25 to 75 with postoperative empyema or hemothorax conventionally treated with drainage without sufficient effect were given intrapleural instillations of streptokinase (Kabikinase, 250,000 IE) for 4 hours). The effects on systemic fibrinolysis were studied. Venous blood samples for determination of fibrinolytic activity on fibrin plates, plasminogen, alpha 2-antiplasmin, alpha 2-macroglobulin, fibrinogen, fibrin(ogen) degradation products (FDP) and thrombin time were taken before instillation, after instillation and then after 24 hours. Preinstillation values were compared to the values 4 and 24 hours after instillation with Student's paired t-test. There were no differences in fibrinolytic activity, alpha 2-macroglobulin and thrombin time. There was a slight increase in plasminogen, alpha 2-antiplasmin and fibrinogen, probably due to an acute phase reaction. Fibrin degradation products showed an increase with border line significance. These changes are not consistent with generalized fibrinolysis, and it is concluded that intrapleural instillations of streptokinase can be given safely in the early posttraumatic or postoperative period.

Adult↗
PubMed1993

Extensive fetal intrathoracic injuries sustained in a motor vehicle accident.

Motor vehicle accidents are the primary nonobstetric cause of maternal and subsequent fetal mortality. We present a case in which blunt abdominal trauma sustained by a pregnant woman in a motor vehicle accident caused extensive intrathoracic fetal injuries consisting of bilateral hemothorax, severe bilateral interstitial pulmonary hemorrhages, hemopericardium, and subepicardial hemorrhages, in addition to fetal cranial injuries. To the best of our knowledge, this is the first report of fetal intrathoracic injuries sustained with blunt maternal trauma. The underlying mechanism of intrathoracic trauma was thought to be similar to that of blast injury with transmission of excessive hydrostatic forces throughout the amniotic fluid with severe impact on the elastic fetal chest. This case supports the concept of in utero blast injury to the fetus as a possible cause for fetal soft tissue trauma associated with blunt trauma to the maternal abdomen.

Accidents, Traffic↗
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↗
PubMedDate not supplied

Thoracic trauma: the deadly dozen.

Deadly Dozen ... Lethal Six ... Hidden Six ... Major thoracic injuries are known as the Deadly Dozen. The Lethal Six (airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest) are immediate, life-threatening injuries that require evaluation and treatment during primary survey. The Hidden Six (thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear, esophageal disruption, and pulmonary contusion) are potentially life-threatening injuries that should be detected during secondary survey. Each of these may present as immediately life-threatening or potentially life-threatening events. This article provides an overview of these 12 injuries and appropriate management for each. Case studies are included.

Combined Modality Therapy↗
PubMed1992

Infectious and mechanical complications of central venous catheters placed by percutaneous venipuncture and over guidewires.

OBJECTIVE: To compare the frequency of infectious and mechanical complications of central venous and pulmonary artery catheters placed by initial venipuncture vs. over a guidewire at existing sites. HYPOTHESIS: Exchange of central venous catheters and pulmonary artery catheters over a guidewire as opposed to fresh venipuncture reduces mechanical complications without increasing risk of infection. DESIGN: Chart audit. PATIENTS: Medical, surgical, and coronary ICU patients requiring invasive monitoring or central venous access. INTERVENTIONS: Patients requiring prolonged catheterization underwent periodic exchange of catheters over a guidewire. Rates of catheter-related infections and mechanical complications were determined for central venous catheters placed by initial venipuncture and those catheters placed by guidewire exchange. MEASUREMENTS AND MAIN RESULTS: Over a 12-month period, 939 catheters were inserted in 454 patients. Of these 939 catheters, 534 were placed by guidewire exchange. Use of a guidewire was associated with a decreased frequency of pneumothorax and hemothorax compared with initial venipuncture (0/405 [0%] vs. 7/534 [1.3%], respectively; p < .05) but not with increased risk of infection (9/405 [2.2%] vs. 14/534 [2.6%], respectively; NS). Guidewire-facilitated replacement of multiple consecutive catheters at the same site did not increase the risk of catheter-related infection. Catheters placed via internal jugular veins were more likely to become infected than catheters placed via subclavian veins (17/477 [3.6%] vs. 3/430 [0.7%], respectively; p < .01). CONCLUSIONS: When prolonged central venous or pulmonary artery catheterization is necessary, periodic catheter replacement over a guidewire is associated with fewer mechanical complications than initial venipuncture. Periodic catheter replacement over a guidewire is also associated with no increase in risk of infection.

Bias↗
PubMed1976

Penetrating stab wounds of the chest: experience with 200 consecutive cases.

The incidence of penetrating wounds of the chest is rising rapidly. Opinions continue to differ on their management. Our experience with 200 consecutive cases of stab wounds of the chest between 1972 and 1975 were reviewed. There were 176 males and 24 females. The average age was 31 years; about two-thirds of the patients were under 30. About 74% presented with hemothorax or hemopneumothorax; 21 presented with pneumothorax. Eleven per cent had associated intra-abdominal injuries. Seventy-nine per cent were successfully treated with tube thoracostomy. About 15% underwent thoracotomy, with three deaths (mortality, 10%); the mortality for cardiac wounds was 16%; overall mortality was 1.5%. The overall complication rate was 5.5%, most occurring in patients with cardiac wounds and associated intra-abdominal injuries. The average period of hospitalization was 6.5 days. Treatment was individualized. Indications for each course of therapy are discussed.

Abdominal Injuries↗
PubMed1979

The etiology of post-traumatic empyema and the role of decortication.

Decortication post-traumatic empyema (PTE) was performed in 27 patients from 1972 through 1977. All 27 patients had penetrating chest wounds and were refractory to antibiotics and tube thoracostomy. Factors associated with PTE included unrecognized diaphragmatic perforation, large hemothorax greater than 500 ml, pulmonary contusion, extrathoracic extension of hematoma within the chest wall, and incomplete expansion of the lung with initial tube thoracostomy. Prophylactic antibiotic usage did not prevent PTE nor lead to negative intrapleural cultures preoperatively. The timing of decortication varied with indication: two patients with infected pneumothorax had surgery within 1 week; 15 patients with infected pleural clot had surgery within 4 weeks; ten including nine who were readmitted to the hospital had surgery more than 4 weeks after injury. Prevention of PTE requires early recognition of hemo- or pneumothorax, early tube thoracostomy with complete evacuation of blood and expansion of lung, careful daily monitoring of subsequent fluid accumulation, and prompt evacuation when such fluid accumulates. Once PTE becomes well established and refractory to standard modalities, decortication with evacuation of the empyema cavity should be performed as soon as possible.

Adolescent↗
PubMed1984

Empyema occurring in the multiply traumatized patient.

During an 11-month period 31 cases of nosocomial empyema were identified in 29 of 741 multiply traumatized patients who remained in our unit for more than 3 days. Nosocomial empyema was defined as purulent culture-positive material drained from the pleural space after five days' hospitalization. All patients had fever and leukocytosis. Possible risk factors included previous aspiration in five patients but none developing pneumonia, prior respiratory tract infection in nine but none with the same pathogen as their empyema, prior antibiotic use in over 50% of the patients, and severe head or chest injury in two thirds of the patients. Thirty-eight pathogens were recovered: S. aureus, 14; beta-streptococci, three; Pseudomonas, six; Klebsiella, two; Enterobacter, two; E. coli, two; other Gram-negative bacilli, six; and anaerobes, three. Fourteen infections were polymicrobic and bacteremia occurred in 42% of the patients. Of these 29 patients, 27 had chest tubes inserted for fluid in the pleural cavity before development of empyema; nine for hemo- or pneumothorax secondary to chest trauma, 11 for pneumothorax while on ventilators, and seven for unexplained sterile pleural effusion. If empyema complicated a prior hemothorax it was usually caused by Staphylococcus aureus and occurred about 10 days after draining blood from the pleural cavity. If empyema was a complication of pneumothorax or serothorax it was usually due to Gram-negative organisms colonizing the upper respiratory tract and occurred within 4 days of draining the fluid. Sixteen per cent of all patients who had chest tubes placed for fluid in their pleural cavity subsequently developed empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

Gunshot wound of the left chest and Bochdalek hernia.

A 16-year-old male presented with a hemopneumothorax following a gunshot wound to the left chest. He was treated effectively with closed suction drainage for 48 hours when he suddenly complained of severe left chest pain. Preoperative diagnosis was suggestive of a traumatic diaphragmatic hernia but operative findings were confirmatory of a rare hernia through the foramen of Bochdalek. Chest X-ray showing a gas-filled viscus above the diaphragm is diagnostic. Increased abdominal pressure generated when he was first hit by the bullet and aggravated by increased negative intrapleural pressure resulting from suction drainage of the hemothorax is the probable mechanism of the herniation.

Adolescent↗
PubMed1986

Tube thoracostomy and trauma--antibiotics or not?

Controversy persists regarding the use of antibiotics in association with t tube thoracostomy for trauma patients. We conducted a prospective randomized study of patients requiring tube thoracostomy for pneumo- and/or hemothorax complicating blunt or penetrating thoracic trauma in an attempt to assess the efficacy of prophylactic antibiotic therapy. Fifty-eight patients were included in the study. The control group (Group I) included 28 patients who received no antibiotic therapy: the experimental group (Group II) included 30 patients who received cefoxitin (1.0 gm IV q 6 h) commencing before tube thoracostomy and terminating 12 hours after its removal. The incidence of infectious complications (pneumonia and/or empyema) was recorded. Among the patients not receiving antibiotics, eight of 28 (29%) developed infectious chest complications. Of the patients receiving antibiotics, there was one infectious complication (3%). This difference is statistically significant (p = 0.0227). Cultures demonstrated significant conversion from negative to positive both within each group and between groups. The organism most commonly recovered was S. aureus. Our findings strongly suggest that patients requiring tube thoracostomy for trauma, whether blunt or penetrating, should receive the benefit of systemic prophylactic antibiotic therapy.

Adolescent↗
PubMed1989

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy.

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

Adolescent↗
PubMed1995

Simple thoracostomy avoids chest drain insertion in prehospital trauma.

Tension pneumothorax and hemothorax are life-threatening emergencies that require immediate treatment. Field stabilization of trauma patients often requires rapid surgical drainage of these injuries but inevitably delays departure for hospital. Conventional treatment involves the insertion of a chest drain but we describe a modified technique of simple thoracostomy that is faster and simpler to perform and avoids the risks associated with insertion of the chest drain. Following use of a simple thoracostomy as an alternative to chest drain insertion in 45 patients at the roadside, this technique appears to have important advantages over conventional techniques and warrants further clinical evaluation.

Adolescent↗
PubMed1997

Video-assisted thoracic surgery in treatment of chest trauma.

Although the indications for video-assisted thoracic surgery (VATS) have expanded rapidly, especially in the areas of therapeutic and operative procedures, its role in the definite surgical treatment of chest trauma is not clear. From July 1994 to December 1995, 56 patients with hemothorax or posthemothorax complications resulting from chest trauma received thoracic surgery. Their ages ranged from 17 to 71 years. Mechanisms of injury included penetrating (n = 23) and blunt injury (n = 33). VATS was successfully applied in 50 patients; six patients with cardiovascular injuries (n = 4) or minor chest wall lacerations (n = 2) did not receive VATS. All patients who received VATS survived, with no morbidity. Twelve of the 50 patients treated with VATS would have otherwise had to undergo thoracotomy. Our results indicate that VATS can be safely used in hemodynamically stable patients with no cardiovascular or great vessel injury, sparing many patients the pain and morbidity associated with thoracotomy. Additionally, use of VATS may reduce the likelihood of posthemothorax complications by allowing early direct inspection of the chest wall, because VATS has a lower associated risk and can be performed with a lower index of suspicion than can standard thoracotomy.

Adolescent↗
PubMed1988

Diaphragmatic pain in pulmonary endometriosis.

The diagnosis of pulmonary endometriosis is difficult and requires a high index of suspicion in patients with pelvic endometriosis. We have reported a case in which a history of periscapular pain associated with menses proved useful in delineating the cause of the hemothorax.

Adult↗
PubMed1993

Mediastinal mass with right pleural effusion.

We have described the case of a 65-year-old man who had a right hemothorax from rupture of an aneurysm of the ascending thoracic aorta and survived. This type of subacute presentation with survival of the patient has not been documented previously in contemporary medical literature.

Aged↗
PubMed2006

Video-based ergonomic analysis to evaluate thoracostomy tube placement techniques.

BACKGROUND: Thoracostomy for relief of pneumo- or hemothorax may be performed emergently at the bedside, in the emergency department or trauma area, often in nonideal circumstances. We hypothesized that ergonomic analysis of thoracostomy techniques can identify areas for potential improvement in patient and operator safety. METHODS: Interviews with Subject Matter Experts (SME) provided steps in the task of thoracostomy; 44 thoracostomies (emergent and elective) were video-recorded and reviewed by SMEs. Ergonomic analyses evaluated surgical performance techniques using video clips. RESULTS: Risks to the patient and operator included instrument-tray positioning and instrument content. Analyses of video records revealed that despite SME-survey consensus, operators inconsistently followed recommended techniques. CONCLUSIONS: Discrepancies between SME-recommended and observed practice are prevalent, with simple ergonomic problems impeding performance, and creating risks for patients and operators. Video-based ergonomic analysis is a rich source for identifying task performance problems and potential solutions.

Chest Tubes↗
PubMed2006

Role of thoracoscopy in acute management of chest injury.

PURPOSE OF REVIEW: To review the literature on the use of video-assisted thoracoscopic surgery for the diagnosis and treatment of intrathoracic injuries. RECENT FINDINGS: Video-assisted thoracoscopic surgery is a relatively recent innovation. It was originally promoted for the treatment of retained hemothorax and the diagnosis of diaphragm injury. It is highly effective for the management of those problems. Recent studies have focused on video-assisted thoracoscopic surgery for treatment of chest wall bleeding, diagnosis of transmediastinal injuries, pericardial window and persistent pneumothorax. In properly selected patients, video-assisted thoracoscopic surgery is extremely efficacious in managing these problems. SUMMARY: The role of video-assisted thoracoscopic surgery in the management of acute chest injury is expanding. It is an invaluable tool for the trauma surgeon.

Contraindications↗
PubMed2005

Early complication of pediatric central venous cannulation.

We describe a case of hemothorax following central venous catheter (CVC) insertion in an infant. Presumably injury occurred as a result of perforation with the dilator. Strategies to reduce the risk of complications and possible factors influencing the unsatisfactory delay in diagnosis, including the role of 'Fixation Error', are discussed.

Achilles Tendon↗