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PubMed1993

Computed tomography in the management of blunt thoracic trauma.

Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.(ABSTRACT TRUNCATED AT 250 WORDS)

Abbreviated Injury Scale↗
PubMed1994

Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma.

Severe blunt chest trauma can produce multiple rib fractures, flail segments, and pulmonary contusions. All of these injuries produce pain and diminished pulmonary function. The effectiveness of intrapleural and epidural administration of bupivacaine was prospectively evaluated in 19 patients with severe chest trauma. Pain relief and pulmonary function were evaluated for 72 hours after catheter placement. Epidural administration of bupivacaine significantly reduced pain at rest and with motion compared with the intrapleural route (p < 0.05). Parenteral narcotic use was also significantly less in the epidural group (p < 0.05). Negative inspiratory pressure and tidal volume were significantly increased with epidural anesthesia (p < 0.05). Vital capacity, FIO2, minute ventilation, and respiratory rate were not affected. Mild hypotension was a common complication with epidural catheters. We conclude that continuous epidural analgesia is superior to intrapleural block and significantly improves tidal volume and negative inspiratory pressure.

Adult↗
PubMed1994

Three-point restraints as a risk factor for chest injury in the elderly.

As the number of drivers over the age of 65 years increases, new trauma patterns are emerging. The use of lap-shoulder restraints, in this population, is beginning to play an important role in new findings about their injuries. Restraint use in motor vehicle crash victims, in relation to average AIS score, ISS, and number of hospital and ICU days, was studied at a level I trauma center. The control group consisted of 100 patients between the ages of 35 and 45 years, who were involved in motor vehicle impacts (MVIs) from January 1990 through January 1992. The study group consisted of 120 patients over the age of 65 years who were involved in MVIs from January 1987 through January 1992. In the control group, restraint use was associated with a lower average AIS score--3.39 versus 7.35 for the unrestrained victims. In addition, the restrained victims spent fewer days in the ICU--0.08 versus 0.30 days for the unrestrained victims; and fewer hospital days--1.08 versus 2.0 days for the unrestrained victims. The general pattern of lower average AIS scores in restrained victims was also seen in the study group. However, in the study group, lap-shoulder belt-restrained patients had higher average AIS scores, in the chest region, than unrestrained patients--0.92 (SE 1.60) versus 0.71 (SE 1.47), respectively. These findings indicate that physicians must be aware of restraint patterns of chest injury in elderly patients. Aggressive triage criteria and vigorous pulmonary toilet, especially in patients with rib fractures, sternal fractures, and pulmonary contusions, should become integral parts of trauma resuscitation protocols in elderly patients.

Age Factors↗
PubMed1995

Anterior lung herniation: another aspect of the seatbelt syndrome.

Shoulder harnesses can be a source of thoracic injury in motor vehicle crashes. Sternal and rib fractures are most commonly reported. We present a case of a traumatic anterior lung herniation secondary to shoulder harness trauma in a motor vehicle crash victim with multiple injuries. A brief review of lung hernias is provided as well as a brief discussion of the thoracic manifestations of the seatbelt syndrome.

Accidents, Traffic↗
PubMed1996

Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury.

AIM: The goal of this study was to describe the epidemiology, clinical presentation, diagnostic methods, and outcome in a large series of children with blunt cardiac injury (BCI). METHODS: A multicenter retrospective review of all individuals less than 18 years of age diagnosed with a BCI from 1983 to 1993 was conducted. Cases included all those with a discharge diagnosis of myocardial contusion, concussion, ventricular disruption, or unspecified BCI. RESULTS: A total of 184 cases of BCI were identified in 16 participating centers. The median age was 7.4 years, and 73% were male. Myocardial contusions accounted for 95% of the diagnoses. The leading mechanisms were motor vehicle crashes involving a pedestrian (39.7%) or passenger (31.0%). The majority (87%) had multiple system trauma, with a mean Injury Severity Score of 27.2 (SD +/- 14.4). Pulmonary contusions were present in 50.5% and rib fractures in 23.0%. The most common diagnostic test performed was a 12-lead electrocardiogram (EKG) (82%), followed by a MB band of creatine phosphokinase (CPK-MB) (69%) and echocardiogram (65%). All three tests were performed in 50%. In these patients, agreement among various diagnostic test pairs was fair (echocardiogram vs. EKG, kappa = 0.27) to poor (echocardiogram vs. CPK-MB, kappa = 0.07 and EKG vs. CPK-MB, kappa = 0.08). No hemodynamically stable patient who presented with a normal sinus rhythm subsequently developed a cardiac arrhythmia or cardiac failure. There were 25 deaths (13.6%), 3 of which were caused by acute pump failure secondary to massive cardiac injury. The remainder died of head or abdominal injuries. Of the 159 (86.4%) patients surviving, 8 (5% of survivors) had significant cardiac sequela, most commonly mitral or tricuspid insufficiency or ventricular septal defect. CONCLUSIONS: Pediatric BCI is usually diagnosed in the context of severe multiple system trauma and is less commonly an isolated event. Because of the lack of a standard, various diagnostic tests are used in the diagnosis of BCI, and these tests rarely agree. In hospitalized pediatric patients with BCI, unanticipated complications are rare. Significant sequela, although uncommon, do occur and follow-up of children with BCI should be ensured.

Accidents, Traffic↗
PubMed1996

Routine transesophageal echocardiography for the diagnosis of aortic disruption in trauma patients without enlarged mediastinum.

OBJECTIVE: To assess the value of routine transesophageal echocardiography (TEE) in diagnosing traumatic disruption of the aorta (TDA) in trauma patients presenting without enlarged mediastinum on chest x-ray films. DESIGN: Prospective study. MATERIALS AND METHODS: TEE was routinely performed to exclude the presence of TDA in patients who sustained severe trauma secondary to abrupt deceleration collisions and presented with an upper mediastinum of fewer than 8 cm on supine chest x-ray films. Patients were divided into two groups according to the presence (group I) or absence (group II) of mediastinal hematoma diagnosed during TEE examination. Radiographic signs regarded as indicators of the presence of TDA were evaluated in both groups. RESULTS: Among the 40 consecutive patients studied, TEE demonstrated two cases of TDA associated with a mediastinal hematoma that were confirmed by both aortography and surgery. One of the patients had a normal mediastinum on presentation chest x-ray films, and the other only exhibited a blurred aortic knob. Radiographic mediastinal abnormalities suggestive of TDA were observed in 13 patients, but chest x-ray films were unremarkable in 12 patients. Twenty patients had multiple rib fractures. The frequency of chest radiographic abnormalities was not significantly higher in group I (n = 6) when compared with group II patients (n = 34). TEE examination demonstrated a normal thoracic aorta in 35 patients and was nondiagnostic in 3 patients (normal aortography). CONCLUSION: TEE should be routinely performed in victims of violent deceleration collisions, even in patients presenting apparently normal mediastinum on supine chest radiography.

Accidents, Traffic↗
PubMed1997

Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST)

BACKGROUND: Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury. METHODS: Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions. RESULTS: Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax; hematuria; pelvic fracture; and thoracolumbar spine fracture. CONCLUSIONS: Up to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.

Abdominal Injuries↗
PubMed1999

Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury.

OBJECTIVES: To determine the sensitivity and utility of emergency sonography for the detection of blunt hepatic injury (BHI) in patients with abdominal trauma and to describe parenchymal sonographic patterns of BHI. METHODS: This report was a prospective clinical study in which the findings of all patients who had emergency sonograms were recorded on a data sheet by the initial sonographer and interpreting physicians. All patients with hepatic injuries during this period were identified and physical examination, laboratory, computed tomographic and intraoperative findings were compared with the prospective data sheets. RESULTS: From January of 1995 to December of 1998, 2,622 emergency sonograms were performed, and in this group, a total of 146 patients had BHI. Emergency sonograms allowed detection of free fluid in 98 patients (67%), and parenchymal injury with no free fluid in seven patients (5%). There were 41 false negatives (28%). The most common pattern identified on a sonogram was a discrete area of increased echogenicity followed by a diffuse hyperechoic pattern. Seventy-six patients (52%) had concomitant intra-abdominal injuries, including spleen (n = 46), bowel (n = 30), and kidney (n = 19). There were 102 exploratory laparotomies performed. Abdominal tenderness or distention was present in 127 patients (87%), and 108 patients had right rib fractures (74%). Based on detection of free fluid, parenchymal injury, or both, the overall sensitivity of sonography for the detection of BHI was 72 % but was 98 % for grade III or higher injuries. CONCLUSION: Emergency sonography is sensitive for the detection of grade III or higher liver injuries resulting from blunt abdominal trauma. Sonography may also reveal BHI on the basis of parenchymal abnormality, with a discrete hyperechoic area the most commonly encountered pattern.

Adolescent↗
PubMed2001

Fatal blunt aortic injuries: a review of 242 autopsy cases.

OBJECTIVE: To characterize fatal blunt aortic injury (BAI). METHODS: A retrospective chart review of 242 cases of fatal BAI in patients who underwent an autopsy at our institution between 1984 and 1997 was performed. Comparisons were made for statistical differences using the z-test. RESULTS: Two hundred forty-two cases of fatal BAI were reviewed, making this the largest BAI autopsy study to date. Mechanisms of BAI included driver/passenger in motor vehicle crash (MVC) (68%), pedestrian versus MVC (17%), and motorcycle crash (8%). When comparing the mechanisms in the time period 1984 to 1988 to the time period 1989 to 1997, only the pedestrian versus MVC mechanism was significantly different (12% vs. 23%, p < 0.05). MVC direction of impact included head-on (45%), lateral (35%), and complex (20%). Two thirds of the victims sustained head injuries, rib fractures, and/or hepatic trauma. Only 58% of the victims had the classic isthmus laceration. There was one preventable death secondary to delay in diagnosis. CONCLUSION: BAI is not limited to frontal impact crashes; there should be a high index of suspicion of BAI in lateral impact crashes as well as pedestrian versus MVC mechanisms. Nonisthmus and complex aortic lacerations are common in fatal BAI. Finally, BAI is a highly lethal injury with few preventable deaths in this series.

Accidents, Traffic↗
PubMed2002

Incidence, severity, and patterns of intrathoracic and intra-abdominal injuries in motorcycle crashes.

BACKGROUND: Although severe head injuries have been reduced with helmet use, little has been done to address the severity of trauma to organs of the trunk in motorcycle crashes. We detail the frequency, severity, and pattern of intrathoracic and intra-abdominal injuries that may be helpful in the recognition and medical treatment of such injuries. METHODS: Diagnostic and treatment information from emergency room, hospital, and coroner records from a cohort of motorcyclists injured from 1991 to 1992 were obtained from 28 hospitals and 11 coroners in California. RESULTS: Multiple intrathoracic and intra-abdominal injuries were common, and the number and bilaterality of rib fractures were strongly associated with chances of injuries to the thoracic and abdominal organs. CONCLUSION: Patients with severe injury in one anatomic region of the trunk are very likely to have severe injuries in the same or other anatomic regions. These patients are best treated in trauma centers, where rapid diagnosis and treatment are possible.

Abdominal Injuries↗
PubMed2002

A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs.

BACKGROUND: A delayed diagnosis of injury to cervicothoracic vessels from blunt trauma may cause significant adverse sequelae. The association of a cervicothoracic seat belt sign with such an injury is unknown. METHODS: Algorithms were prospectively studied for the detection of occult vascular injury in patients with cervicothoracic seat belt signs. Patients with neck seat belt signs underwent arteriography or computed tomographic angiography (CTA). Those with thoracic seat belt signs underwent aortography/arteriography if a ruptured thoracic aorta or injury to a great vessel was suspected or a neurovascular abnormality was present. RESULTS: During a 17-month period, 797 patients were admitted to the trauma service secondary to motor vehicle crashes. One hundred thirty-one (16.4%) had cervical or thoracic seat belt signs. Four (3%) of the patients had carotid artery injuries, the presence of which was strongly associated with a Glasgow Coma Scale score < 14, an Injury Severity Score > 16 (p < 0.0001), and the presence of a clavicle and/or first rib fracture (p < 0.0037). Of the remaining patients, 17 had thoracic trauma. There were no vascular injuries in the children and only one had thoracic trauma. CONCLUSION: The algorithms are safe and accurate for the detection of cervicothoracic vascular injury in adult and pediatric patients with seat belt signs. The cervicothoracic seat belt mark and an abnormal physical examination are an effective combination in screening for cervicothoracic vascular injury.

Accidents, Traffic↗
PubMed2002

Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.

BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups. RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19). CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

Flail Chest↗
PubMed2002

18FDG PET versus high-dose 67Ga scintigraphy for restaging and treatment follow-up of lymphoma patients.

To date, only one published study has directly compared 67Ga scintigraphy (low dose, planar) with planar dual-head gamma camera 18F-fluorodeoxyglucose (18FDG) imaging for the purpose of treatment follow-up monitoring in lymphoma patients, and no data on restaging are available. The present study reports the direct comparison of high-dose (297-370 MBq) 67Ga planar and single photon emission computed tomography (SPECT) imaging and conventional 18FDG positron emission tomography (PET) for restaging and treatment follow-up of lymphoma patients versus a gold standard consisting of morphological imaging, including plain radiography and computed tomography (CT) scanning, bone marrow examination and long-term follow-up (<12 months). Sixteen patients, 10 with non-Hodgkin's lymphoma and six with Hodgkin's disease, were included (10 men, six women; median age, 43 years; range, 16-64 years). The median follow-up time was 27 months (range, 12-34 months). In two patients, 67Ga and 18FDG PET (370 MBq) were performed twice, resulting in 18 cross-sectional episodes. In 11 episodes, the results obtained by both imaging modalities were in agreement with regard to the presence or absence of disease when compared with the gold standard. However, the abnormalities found on 18FDG PET were always more extensive. In two episodes, 67Ga imaging normalized after treatment, whereas PET showed significant regression followed by subsequent normalization. In four additional episodes, 67Ga images were negative, whereas 18FDG PET visualized non-tumour-related pathology, such as lung infection, rib fracture or dense thymic tissue. In one gold standard-negative patient, the underlying cause of sternal FDG uptake remained undetermined. The data presented, although limited in number, suggest that 18FDG PET performs better than Ga imaging in monitoring lymphoma disease status. However, a correlation with clinical history and a knowledge of the characteristics of benign lesions are mandatory. Further studies are recommended.

Adolescent↗
PubMedDate not supplied

Long-term sequelae following blunt thoracic trauma.

People experiencing blunt thoracic trauma may sustain multiple rib fractures, flail chest, cardiac or pulmonary contusions, injury to the great vessels, sternal fractures, clavicular fractures, neck injuries, and lacerations of the liver and/or spleen. Long-term sequelae from blunt chest trauma include chest wall deformities, persistent dyspnea, and cardiac, neurologic, or esophageal complications. Chronic pain, depression, and loss of functional status are also frequent components of recovery from trauma.

Humans↗
PubMed1999

Differences between scar and dermal cultured fibroblasts derived from a patient with recurrent abdominal incision wound herniation.

Fibroblasts were derived from dermis and scar of a 47-year-old white man with a recurrent incisional hernia as a result of fractured ribs. The scar was thin and stretched, suggesting a defect in the maturation of granulation tissue. After surgical repair, biopsy specimens of discarded scar and skin were used to generate fibroblast cell lines. Fibroblasts maintained in medium containing 10% fetal bovine serum and antibiotic were studied between their third and eighth passage. By phase contrast microscopy, no structural differences were obvious, but it was noted that to pass scar fibroblasts, a more aggressive trypsin regimen was required. Immunohistologic and Western blot analysis of patient scar fibroblasts showed (1) more a smooth muscle actin within stress fibers, (2) increased expression of the vitronectin integrin receptor alpha(v) (CD 51), and (3) reduced expression of the collagen integrin receptor alpha2 (CD 49b). The expression of vinculin from focal adhesions or a tubulin from microtubules was the same among cell lines. Contractions of scar and dermal fibroblast-populated collagen lattice were compared. At 24 hours, contractions were 69 percent with newborn fibroblasts (normal); 68 percent for patient dermal fibroblasts; and only 48 percent for patient scar fibroblasts. The retarded contraction of scar fibroblast-populated collagen lattice was significant (p > or = 0.002). Myosin ATPase activity, critical for lattice contraction, and cell migration were equivalent among all cell lines. A plausible mechanism for the retardation of scar lattice contraction is disruption of fibroblasts and collagen interactions, for which the attachment of cells to collagen is altered. It is proposed that either the decrease in the expression of collagen integrin receptor alpha2 (CD 49b), an increase in the expression of the vitronectin receptor alpha(v) (CD 51), or a combination of both is responsible for disruption of collagen fibroblast interactions.

Actins↗
PubMed2001

Posterior atlanto-occipital dislocation and concomitant discoligamentous C3-C4 instability with survival.

STUDY DESIGN: A case report is presented. OBJECTIVES: To describe the diagnostic procedure, treatment, and outcome of a 56-year-old man with posterior atlanto-occipital dislocation and concomitant discoligamentous C3-C4 instability. CASE REPORT: A 56-year-old male seat-belted driver of a car was involved in an accident. After initial spontaneous breathing and weak movements of all his extremities, artificial respiration became necessary because of increasing respiratory insufficiency. Radiologic diagnostics, including computed tomography scans, showed a posterior atlanto-occipital dislocation and a Grade 2 craniocerebral trauma with occipital subarachnoidal bleeding. Further examination showed a serial rib fracture with concomitant hemopneumothorax. After stabilization of the patient, magnetic resonance imaging of the cervical spine showed a contusion of the upper cervical spinal cord. Additionally, rupture of the interspinal ligaments and the posterior longitudinal ligament could be seen, as well as a rupture of the intervertebral C3-C4 disc. Operative stabilization was performed by posterior fusion of C0-C4 using the CerviFix-System and autogenous bone grafts taken from the iliac crest. At 12 months after the operation, the patient had only slight weakness of the left arm and a 70% limitation in the range of motion of the cervical spine. CONCLUSIONS: With improvements in advanced trauma life support, the number of patients with atlanto-occipital dislocation admitted to hospital alive is increasing, so this particular lesion must be kept in mind. When the patient survives the accident, the long-term prognosis is quite good, with a high rate of recovery after initial neurologic deficits.

Accidents, Traffic↗