Demetri L, Martinez Aguilar MM, Bohnen JD, Whitesell R, Yeh DD, King D, de Moya M.
J Trauma Acute Care Surg. 2018 Mar;84(3):454-458
BACKGROUND: Eastern Association for the Surgery of Trauma guidelines suggest tube thoracostomy (TT) be considered for all traumatic hemothoraces. However, previous research has suggested that some traumatic hemothoraces may be observed safely. We sought to (1) determine the safety of selective observation for traumatic hemothorax and (2) identify predictors of failed observation.
METHODS: All patients with traumatic hemothorax from 2000 to 2014 at a Level I trauma center were identified and categorized by size as small (<300 cc) or large (≥300 cc) based on chest computed tomography (CT) scan measurements. Patients with no CT or with TT placement before CT were excluded. Patients were categorized into four intervention groups: (i) early TT (<24 hours after CT), (ii) failed observation (TT ≥24 hours after CT), (iii) successful observation (no TT), and (iv) inevaluable due to early mortality (no TT but died within 7 days). Univariate analyses compared outcomes between groups. Multivariate analyses identified independent predictors of failed observation.
RESULTS: Three hundred forty patients met the inclusion criteria. 156 (46%) patients received early TT. Of the 184 patients that were initially observed, 121 (66%) were successfully observed, 53 (29%) failed observation, and 10 (5%) were inevaluable due to early mortality. Most of the successfully observed hemothoraces were small (119/121, 98%). Four independent predictors of failed observation were identified: older age, fewer ventilation-free days, largehemothorax, concurrent pneumothorax. Patients, who received TT were more likely than non-TT patients to receive tissue plasminogen activator, develop an empyema, have fewer hospital-free days, and are discharged to rehabilitation rather than home. When compared to early TT, failed observation was associated with a higher likelihood of discharge to rehabilitation but no difference in mortality, hospital-free days, or rate of empyema.
CONCLUSION: Initial observation in select patients is safe and may result in better outcomes. The identified predictors of failed observation can help in clinical decision making regarding the need for TT in patients with traumatic hemothorax.LEVEL OF EVIDENCE: Therapeutic/care management, level IV.
Gupta A, Rattan A, Kumar S, Rathi V
J Clin Diagn Res. 2017 Sep;11(9):PD12-PD13
ABSTRACT:A 13-year-old girl, who did not receive any treatment for few hours following Road Traffic Injury (RTI), reported to the Casualty Department and found to have patent airway with clinically normal C spine, air-hunger (RR 42/minute), trachea deviated to left, distended neck veins and absent breath sounds on the right side. The chest X-ray she carried, done immediately after the injury, showed right sided tension pneumothorax. She was put on oxygen at 11 L/minute and an Intercostal chest tube drainage (ICD) was inserted on right side. Her oxygen saturation (40%) failed to improve. ICD bag showed continuous bubbling and air entry remained absent on the right side. An urgent right thoracotomy was done which revealed right main bronchus tear; the tear was repaired using interrupted Prolene® sutures. Patient recovered well and was discharged 10 days later in a stable condition.
Keneally RJ, Szpisjak DF, Hoffmann PJ, Park EJ, Albergo MS
Mil Med. 2017 Nov;182(11):e1881-e1884
BACKGROUND: Triage is the act of stratifying the need for medical attention. Effective triage must account for injury patterns and severity. Personnel making triage decisions must also consider the patients' physiologic states. Vital signs can possibly be used to assess for the presence of physiological derangements such as coagulopathy, acidosis, or a significant base deficit. Providers could use this knowledge to assist with triage at casualty collection points where laboratory studies or point of care testing may not be available.
METHODS: With institutional approval, data were extracted from the Joint Theater Trauma Registry for all patients with thoracic trauma between 2002 and 2012. Patients were identified by International Statistical Classification of Diseases and Related Health Problems, 9th Revision (ICD-9) codes. Heart rate (HR), systolic blood pressure (SBP), and pulse pressure were correlated with coagulopathy (international normalization ratio ≥ 1.5), acidosis (pH < 7.2) or an elevated base deficit (>6) on admission. Sensitivity, specificity, positive predictive values, negative predictive values, and odds ratios were calculated.
FINDINGS: HR > 100, SBP < 90, or pulse pressure <30 were associated with an increased risk for acidosis (odds ratio 3.06 [95% confidence interval 2.48-3.78], 4.72 [3.85-5.78], and 2.73 [2.15-3.48], respectively), coagulopathy (2.21 [1.72-2.83], 4.55 [3.57-5.80], and 2.73 [2.15-3.48], respectively), and base deficit >6 (2.17 [1.88-2.50], 3.48 [2.87-4.22], and 2.22 [1.78-2.77], respectively). HR was a moderately sensitive marker (0.74), whereas SBP was a specific marker (0.93).
DISCUSSION: SBP < 90 is an effective marker for ruling in physiologic derangement after thoracic trauma. HR > 100 was associated with over twice the odds for physiologic derangement. Vital signs can be used to assess for physiologic derangement in the population studied and may help in triage.
Mercurio I, Capano D, Torre R, Taddei A, Troiano G, Scialpi M, Gabbrielli M.
Am J Forensic Med Pathol. 2018 Mar;39(1):61-68
ABSTRACT:Cerebral air embolism is caused by gas bubbles in the vascular system. These bubbles can cause cerebral ischemia by obstructing encephalic blood vessels. It is frequently associated with blunt and penetrating chest trauma as well as iatrogenic interventions. Lung trauma involving laceration of the respiratory tract, lung parenchyma, and blood vessels may result in direct communication of these structures, driving air or gas into the pulmonary venous system. We report a case of a blunt chest trauma that led to massive arterial air embolism that was possible to recognize with the help of postmortem computed tomographic scan examination.
Schellenberg M, Inaba K
Emerg Med Clin North Am. 2018 Feb;36(1):135-147
Traumatic injuries to the thorax are common after both blunt and penetrating trauma. Emergency medicine physicians must be able to manage the initial resuscitation and diagnostic workup of these patients. This involves familiarity with a range of radiologic investigations and invasive bedside procedures, including resuscitative thoracotomy. This knowledge is critical to allow for rapid decision making when life-threatening injuries are encountered. This article explores the initial resuscitation and assessment of patients after thoracic trauma, discusses available imaging modalities, reviews frequently performed procedures, and provides an overview of the indications for operative intervention, while emphasizing the critical decision making throughout.
Singh AK, Verma J, Kumar S
Indian J Crit Care Med. 2017 Nov;21(11):783-785
Cerebral air embolism is a rare clinical entity in day-to-day practice. The introduction of air into the venous or the arterial system can cause cerebral air embolism leading to severe neurological deficits. The common causes reported in the literature are iatrogenic; it can be caused by positive pressure maneuvers performed during cardiac resuscitation, lung biopsy, and the placement of venous catheters in the presence of a patent foramen ovale. We report a case of cerebral air embolism which has occurred secondary to lung laceration. The patient underwent intercostal drainage for hydro-pneumothorax and developed forceful cough and suddenly changed in consciousness. Air embolism was diagnosed by computed tomography brain and was managed by high-concentration oxygen therapy and other supportive measures and is being discharged in satisfactory condition.
Kuckelman J, Derickson M, Phillips C, Barron M, Marko S, Eckert M, Martin M
Am J Surg. 2018 Jan 5. pii: S0002-9610(17)31602-1.
INTRODUCTION: Tension pneumothorax (tPTX) remains a major cause of preventable death in trauma. Needle decompression (ND) has up to a 60% failure rate.
METHODS: Post-mortem swine used. Interventions were randomized to 14G-needle decompression (ND, n = 25), bladed trocar with 36Fr cannula (BTW, n = 16), bladed trocar alone (BTWO, n = 16) and surgical thoracostomy (ST = 11). Simulated tPTX was created to a pressure(p) of 20 mmHg.
RESULTS: Success (p < 5 mmHg by 120 s) was seen in 41 of 68 (60%) interventions. BTW and BTWO were consistently more successful than ND with success rates of 88% versus 48% in ND (p < .001). In successful deployments, ND was slower to reach p < 5 mmHg, average of 82s versus 26s and 28s for BTW and BTWO respectively (p < .001). Time to implement procedure was faster for ND with an average of 3.6s versus 16.9s and 15.3s in the BTW and BTWO (p < .001). Final pressure was significantly less in BTW and BTWO at 1.7 mmHg versus 7 mmHg in ND animals (p < .001).
CONCLUSION: Bladed trocars can safely and effectively tPTX with a significantly higher success rates than needle decompression.
Naik ND, Hernandez MC, Anderson JR, Ross EK, Zielinski MD, Aho JM
Chest. 2017 Nov;152(5):1015-1020
BACKGROUND: The success of needle decompression for tension pneumothorax is variable, and there are no objective measures assessing effective decompression. Colorimetric capnography, which detects carbon dioxide present within the pleural space, may serve as a simple test to assess effective needle decompression.
METHODS: Three swine underwent traumatically induced tension pneumothorax (standard of care, n = 15; standard of care with needle capnography, n = 15). Needle thoracostomy was performed with an 8-cm angiocatheter. Similarly, decompression was performed with the addition of colorimetric capnography. Subjective operator assessment of decompression was recorded and compared with true decompression, using thoracoscopic visualization for both techniques. Areas under receiver operating curves were calculated and pairwise comparison was performed to assess statistical significance (P < .05).
RESULTS: The detection of decompression by needle colorimetric capnography was found to be 100% accurate (15 of 15 attempts), when compared with thoracoscopic assessment (true decompression). Furthermore, it accurately detected the lack of tension pneumothorax, that is, the absence of any pathologic/space-occupying lesion, in 100% of cases (10 of 10 attempts). Standard of care needle decompression was detected by operators in 9 of 15 attempts (60%) and was detected in 3 of 10 attempts when tension pneumothorax was not present (30%). True decompression, under direct visualization with thoracoscopy, occurred 15 of 15 times (100%) with capnography, and 12 of 15 times (80%) without capnography. Areas under receiver operating curves were 0.65 for standard of care and 1.0 for needle capnography (P = .002).
CONCLUSIONS: Needle decompression with colorimetric capnography provides a rapid, effective, and highly accurate method for eliminating operator bias for tension pneumothorax decompression. This may be useful for the treatment of this life-threatening condition.
Sharayah A, Unnikrishnan D, Shukla PS, Livornese D
BMJ Case Rep. 2017 Dec 13;2017. pii: bcr-2017-223530. doi: 10.1136/bcr-2017-223530.
No abstract on PubMed