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1
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Siddiqui HA, Maginot ER, Moody TB, Henry R, Barrett CD. Pleural Space Diseases and Their Management: What is the Role of Intrapleural Fibrinolytic Therapy? Am Surg 2025; 91:1036-1045. [PMID: 40178072 DOI: 10.1177/00031348251331281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2025]
Abstract
Pleural space diseases are a significant cause of morbidity in the United States with a reported 25% mortality rate within a year of diagnosis. Pleural space diseases, including intrapleural infections, retained hemothorax (RH), and malignant pleural effusions (MPE), often indicate advanced disease. Despite options like video-assisted thoracoscopy (VATS), tube thoracostomy, and intrapleural fibrinolytic therapy (IPFT), treatment remains a significant clinical challenge. IPFT, which describes a combination of administrating tissue plasminogen activator (tPA) and DNase through a chest tube, has shown effectiveness in improving fluid drainage and reducing surgery frequency in a large, randomized control trial and is widely used. However, the success of IPFT varies based on infection severity, patient health, and treatment timing, with a failure rate around 20-25%. This highlights the need for further research to enhance the therapy's efficacy, investigating both disease mechanisms and optimizing treatment protocols. This review seeks to provide a comprehensive overview of IPFT, highlighting recent advancements, current trends, and existing research gaps.
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Affiliation(s)
- Halima A Siddiqui
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth R Maginot
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Trace B Moody
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Reynold Henry
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Christopher D Barrett
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Cellular and Integrative Physiology, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Lee C, Nahmias J, Lekawa M, Fairbairn K, Grigorian A. Video-Assisted Thoracoscopy in Pediatric Thoracic Trauma. Am Surg 2025:31348251341964. [PMID: 40340718 DOI: 10.1177/00031348251341964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2025]
Abstract
Pediatric thoracic trauma is a major cause of pediatric morbidity and mortality. Pediatric patients have unique anatomy and physiology that account for differences in injury patterns when compared to adult patients. These differences warrant special consideration in injury recognition and intraoperative management. The initial management of pediatric thoracic trauma should follow the principles of the primary survey in that life-threatening injuries should be ruled out. Hemodynamically unstable patients with serious thoracic injury warrant thoracotomy for expeditious management of life-threatening conditions. However, the management of hemodynamically stable patients with thoracic injury has evolved with the advent of minimally invasive surgery and the well-documented benefits of video-assisted thoracoscopic surgery (VATS) compared to traditional thoracotomy. Multiple studies have shown that VATS can be performed safely and effectively for traumatic injuries in children in both the acute and delayed setting. In this article, we provide an overview of pediatric thoracic trauma and the use of VATS in the management of these conditions.
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Affiliation(s)
- Carlin Lee
- Department of Surgery, Division of Trauma, Burn, Critical Care & Acute Care Surgery, University of California Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burn, Critical Care & Acute Care Surgery, University of California Irvine, Orange, CA, USA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burn, Critical Care & Acute Care Surgery, University of California Irvine, Orange, CA, USA
| | - Kelly Fairbairn
- Department of Surgery, Division of Thoracic Surgery, University of California Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burn, Critical Care & Acute Care Surgery, University of California Irvine, Orange, CA, USA
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Ahmed K, Al-Hassani A, El-Menyar A, Nabir S, Ahmed MN, Almadani A, Mahmood I, Mekkodathil A, Peralta R, Rizoli S, Al-Thani H. Time to resolution of radiologically detected hemothorax in trauma patients: A retrospective observational study. World J Radiol 2025; 17:105960. [PMID: 40309476 PMCID: PMC12038407 DOI: 10.4329/wjr.v17.i4.105960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/15/2025] [Accepted: 03/26/2025] [Indexed: 04/22/2025] Open
Abstract
BACKGROUND Traumatic hemothorax is a common complication of chest trauma; however, the timeline for its resolution, even with chest tube thoracostomy, remains unclear. AIM To determine the time to resolution of the hemothorax to ensure safe discharge based on chest radiography (CXR) findings. METHODS A retrospective observational study was conducted at Hamad General Hospital, Qatar, from June 2014 to October 2019, including all patients with hemothorax diagnosed via computed tomography (CT) following chest trauma. Based on the initial imaging study, the hemothorax was divided into right, left, and bilateral. RESULTS The study included 422 patients. Of the total, 57.82% (n = 244/422) resolved their hemothorax within three days of admission. Among these, 44 patients required chest tube insertion (CTI) and 200 were cleared without it. Between days 3 and 7, an additional 16.83% (n = 71 /422) of cases were resolved, of which 28 required chest tubes. By days 8 to 14, another 11.37% (n = 48/422) were cleared, with 15 patients requiring chest tubes. After 14 days, 13.98% (n = 59/422) of patients still had hemothorax, 14 of whom required CTI. CONCLUSION This study showed that a subset of patients continued to experience retained hemothorax despite early tube thoracostomy. Patients with a larger hemothorax, particularly on the left side, showed prolonged resolution times. Regular imaging such as CXR or CT is recommended for up to 14 days post-intervention. After this period, outpatient follow-up is generally safe, although some patients may still have a persistent hemothorax beyond two weeks.
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Affiliation(s)
- Khalid Ahmed
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma, and Vascular Surgery, Doha 24144, Qatar
- Clinical Medicine, Weill Cornell Medical College, Qatar Foundation-Education City, Doha 24144, Qatar
| | - Syed Nabir
- Department of Radiology, Hamad Medical Corporation, Doha 3050, Qatar
| | | | - Ammar Almadani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
| | - Ismail Mahmood
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
| | | | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
- Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo 10100, Dominican Republic
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation (HMC), Doha 3050, Qatar
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McCartt J, Ross SW, Cunningham KW, Wang H, Sealey L, Brake J, Christmas A, Sachdev G, Green J, Thomas BW. A Randomized Non-Inferiority Clinical Trial of 14Fr Thal versus 28Fr Tube Thoracostomy for Traumatic Hemothorax. Am Surg 2025; 91:579-586. [PMID: 39700058 DOI: 10.1177/00031348241308907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2024]
Abstract
BackgroundThe traditional treatment of traumatic hemothorax (HTX) is large bore chest tubes (CT) ≥28Fr. Recent evidence shows 14Fr pigtail catheters are as effective in drainage of HTX as larger CT. However, this has not been shown in 14Fr Thal tubes, a straight chest tube placed utilizing Seldinger technique.MethodsA single center, prospective randomized controlled trial was performed at an ACS verified Level 1 trauma center comparing 14Fr Thal CT (14CT) to 28Fr CT (28CT) between May 2017 and September 2021. The primary outcome was failure of drainage of hemothorax requiring additional intervention. Secondary outcomes included duration of chest tube placement, length of stay, tube-specific complications, and 90-day hospital readmission. Farrington-Manning approach was used for non-inferiority tests. Wilcoxon 2-samples test or t test was used for continuous variables, and Pearson chi-square or Fisher exact test was used for categorical variables.Results109 patients were included in the randomized trial. There were 54 patients in the 14CT cohort, and 55 patients in the 28CT cohort. The primary outcome of drainage failure was similar between groups (8.3% 14CT vs 3.9% 28CT). Using a 15% non-inferiority margin 14CT is non-inferior to 28CT. No differences were identified in secondary outcomes.Conclusion14Fr Thal tubes have similar efficacy in drainage of traumatic hemothorax when compared with 28Fr chest tubes with similar complication rates (NCT03167723).
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Affiliation(s)
- Jason McCartt
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel Wade Ross
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Kyle W Cunningham
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Huaping Wang
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Leslie Sealey
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Julia Brake
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Ashley Christmas
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Gaurav Sachdev
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - John Green
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Bradley W Thomas
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
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Seok J, Yoon SY, Han J, Kim Y, Hong JM. Prediction Model of Delayed Hemothorax in Patients with Traumatic Occult Hemothorax Using a Novel Nomogram. J Chest Surg 2024; 57:519-528. [PMID: 39327475 PMCID: PMC11538589 DOI: 10.5090/jcs.24.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/16/2024] [Accepted: 07/23/2024] [Indexed: 09/28/2024] Open
Abstract
Background Delayed hemothorax (dHTX) can occur unexpectedly, even in patients who initially present without signs of hemothorax (HTX), potentially leading to death. We aimed to develop a predictive model for dHTX requiring intervention, specifically targeting those with no or occult HTX. Methods This retrospective study was conducted at a level 1 trauma center. The primary outcome was the occurrence of dHTX requiring intervention in patients who had no HTX or occult HTX and did not undergo closed thoracostomy post-injury. To minimize overfitting, we employed the least absolute shrinkage and selection operator (LASSO) logistic regression model for feature selection. Thereafter, we developed a multivariable logistic regression (MLR) model and a nomogram. Results In total, 688 patients were included in the study, with 64 cases of dHTX (9.3%). The LASSO and MLR analyses revealed that the depth of HTX (adjusted odds ratio [aOR], 3.79; 95% confidence interval [CI], 2.10-6.85; p<0.001) and the number of totally displaced rib fractures (RFX) (aOR, 1.90; 95% CI, 1.56-2.32; p<0.001) were significant predictors. Based on these parameters, we developed a nomogram to predict dHTX, with a sensitivity of 78.1%, a specificity of 76.0%, a positive predictive value of 25.0%, and a negative predictive value of 97.1% at the optimal cut-off value. The area under the receiver operating characteristic curve was 0.832. Conclusion The depth of HTX on initial chest computed tomography and the number of totally displaced RFX emerged as significant risk factors for dHTX. We propose a novel nomogram that is easily applicable in clinical settings.
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Affiliation(s)
- Junepill Seok
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, Korea
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Su Young Yoon
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jonghee Han
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Yook Kim
- Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea
- Department of Radiology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong-Myeon Hong
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, Korea
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
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Vivekanandan DD, Louis M, Canaan LN, Gersch K. Can Intrapleural Tissue Plasminogen Activator and Deoxyribonuclease Be Used to Treat Persistent Hemothorax After Robotic Lobectomy? Cureus 2024; 16:e73999. [PMID: 39703319 PMCID: PMC11657300 DOI: 10.7759/cureus.73999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2024] [Indexed: 12/21/2024] Open
Abstract
Hemothorax is a serious complication following thoracic surgery, often resulting from vessel injury or rib fractures, and is typically managed with chest tube drainage. Persistent or loculated hemothorax, referred to as retained hemothorax, may require more invasive interventions, such as thoracotomy. Although the intrapleural administration of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) has shown promise in managing pleural infections, its use for hemothorax remains controversial due to bleeding risks. We present a case of a 74-year-old female who developed a retained hemothorax following a robotic left upper lobectomy for lung cancer. Initial chest tube drainage was insufficient, and her high-risk status rendered her unsuitable for further surgery. After a thorough evaluation and obtaining informed consent, intrapleural tPA and DNase were administered, resulting in significant clinical and radiographic improvement without complications. This case suggests that intrapleural tPA and DNase may be a potential alternative to surgery for managing retained hemothorax. Further studies are needed to establish treatment guidelines.
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Affiliation(s)
| | - Mena Louis
- General Surgery, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Lucas N Canaan
- Surgery, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Karen Gersch
- Cardiothoracic Surgery, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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Na H, Kim EJ, Muller A, Butts C, Reilly E, Geng T, Romeo M, Ong A. Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention. Am Surg 2024; 90:2232-2237. [PMID: 38780449 DOI: 10.1177/00031348241256087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.
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Affiliation(s)
- HeeYun Na
- Drexel University College of Medicine, Wyomissing, PA, USA
| | - Esther J Kim
- Department of Surgery, Reading Hospital, West Reading, PA, USA
| | - Alison Muller
- Department of Surgery, Reading Hospital, West Reading, PA, USA
| | | | - Eugene Reilly
- Department of Surgery, Reading Hospital, West Reading, PA, USA
| | - Thomas Geng
- Department of Surgery, Reading Hospital, West Reading, PA, USA
| | - Michael Romeo
- Department of Radiology, Reading Hospital, West Reading, PA, USA
| | - Adrian Ong
- Department of Surgery, Reading Hospital, West Reading, PA, USA
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Baseer A, Noor N, Aman N, Qureshi AN. Utilizing Un-enhanced Chest Computed Tomography Screening for Blunt Trauma Surgery Decisions. Cureus 2024; 16:e69590. [PMID: 39421075 PMCID: PMC11484533 DOI: 10.7759/cureus.69590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2024] [Indexed: 10/19/2024] Open
Abstract
Background Blunt chest trauma is a common and potentially life-threatening condition that requires prompt assessment for potential surgical intervention. Computed tomography (CT) of the chest has emerged as a valuable tool due to its heightened sensitivity and specificity in detecting thoracic injuries compared to conventional chest radiography. Objective This study aims to assess the impact of non-contrast CT chest findings on surgical decision-making and compare these findings with those from chest radiographs. Methods The study was conducted at the Accident and Emergency Department of Medical Teaching Institute, Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan. Patients of all ages and genders who presented with blunt chest trauma were included. Non-contrast CT chest scans were used as an initial screening tool and compared with traditional chest radiographs. Data collected included patient demographics, mechanism of injury, diagnostic findings, and treatment decisions. Imaging was performed using a GE Optima 16-slice scanner (Medsystems Sp. z o.o., Lublin, Poland). Results The study included 246 patients, of whom 210 (85.4%) were males. The most common age group was 50 years or older, comprising 71 (28.9%) of the sample. The predominant mechanism of trauma was road traffic accidents, reported by 188 (76.4%) patients. Hemopneumothorax was detected in 121 (49.2%) patients on CT scans compared to 34 (13.8%) patients on chest radiographs. On chest radiograph, the pneumothorax component was missed in 43 (17.5%) patients, and the hemothorax component was not detected in 21 (8.5%) patients. Patient management included conservative management in 30 (12.2%) cases and surgical intervention in the form of unilateral tube thoracostomy in 173 (70.3%) patients or bilateral tube thoracostomy in 43 (17.5%) patients. Conclusion Our study supports the use of non-contrast CT scans as a reliable diagnostic tool for blunt chest trauma, consistent with current literature. This approach facilitates prompt management decisions, particularly for initiating tube thoracostomy based on findings of pneumothorax and hemothorax. The rarity of mediastinal great vessel trauma further justifies minimizing routine contrast use, thereby enhancing the efficiency of trauma evaluations.
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Affiliation(s)
- Abdul Baseer
- Cardiothoracic Surgery, Medical Teaching Institute, Lady Reading Hospital, Peshawar, PAK
| | - Nosheen Noor
- Radiology, Medical Teaching Institute, Lady Reading Hospital, Peshawar, PAK
| | - Nasreen Aman
- Radiology, Medical Teaching Institute, Lady Reading Hospital, Peshawar, PAK
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Mohamad Jailaini MF, Hashim Y, Abdul Hamid MF. Revamping hemothorax management: The promise of low-dose intrapleural fibrinolytic therapy as an alternative. Respirol Case Rep 2024; 12:e70012. [PMID: 39188573 PMCID: PMC11347044 DOI: 10.1002/rcr2.70012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/19/2024] [Indexed: 08/28/2024] Open
Abstract
Surgical evacuation has long been the standard treatment for hemothorax. However, some patients are not suitable candidates for surgery. Intrapleural fibrinolytic therapy (IPFT) has recently emerged as an effective alternative for managing retained hemothorax. This case report describes two patients with retained hemothorax who were unfit for surgery and were successfully treated with IPFT at our centre. Both patients were deemed unsuitable for surgery due to comorbidities and their overall functional status. They received three cycles of IPFT, each consisting of 2.5 mg of alteplase. This treatment effectively evacuated the retained hemothorax, achieving complete radiological resolution without immediate or delayed complications up to 3 months post-discharge.
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Affiliation(s)
| | - Yusra Hashim
- Respiratory Unit, Faculty of MedicineUniversiti Kebangsaan Malaysia (UKM)Kuala LumpurMalaysia
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Srinivas S, Henderson K, Bergus KC, Jacobs A, Baselice H, Donnelly E, Valdez C, Tracy BM, Coleman JR. Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review. J Trauma Acute Care Surg 2024; 97:82-89. [PMID: 38480497 DOI: 10.1097/ta.0000000000004314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. METHODS We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. RESULTS There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. CONCLUSION Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Shruthi Srinivas
- From the Department of Surgery (S.S., K.C.B.), College of Medicine (K.H.), Department of Radiology (A.J.), Division of Trauma, Critical Care, and Burns, Department of Surgery (H.B., C.V., B.M.T., J.R.C.), and Division of Thoracic Imaging, Department of Radiology (E.D.), The Ohio State University, Columbus, Ohio
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Messa GE, Fontenot CJ, Deville PE, Hunt JP, Marr AB, Schoen JE, Stuke LE, Greiffenstein PP, Smith AA. Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma. Am Surg 2024:31348241241735. [PMID: 38557288 DOI: 10.1177/00031348241241735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma. METHODS A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed. RESULTS Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX. DISCUSSION In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.
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Affiliation(s)
- Genevieve E Messa
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
| | - Cameron J Fontenot
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
| | - Paige E Deville
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
| | - Alan B Marr
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
| | - Jonathan E Schoen
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
| | - Lance E Stuke
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
| | - Patrick P Greiffenstein
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
| | - Alison A Smith
- Department of Surgery, Louisiana State University Health New Orleans, School of Medicine, New Orleans, LA, USA
- Trauma and Critical Care, University Medical Center New Orleans, New Orleans, LA, USA
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Nishino T, Tsuchiya A, Morita S, Nakagawa Y. Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt. BMJ Case Rep 2023; 16:e254265. [PMID: 38142055 DOI: 10.1136/bcr-2022-254265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.
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Affiliation(s)
- Tomoya Nishino
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
| | - Seiji Morita
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Yoshihide Nakagawa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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13
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Nguyen S, Torralba EJ, Clark N, Lesch H, Layba C. Endograft Control of Hemorrhage From Traumatic Avulsion of Multiple Intercostal Arteries. Am Surg 2023; 89:6287-6289. [PMID: 36787982 DOI: 10.1177/00031348231157409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- Sandra Nguyen
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Ericson John Torralba
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Nicolette Clark
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Heather Lesch
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Cathline Layba
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
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14
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Beeton G, Ngatuvai M, Breeding T, Andrade R, Zagales R, Khan A, Santos R, Elkbuli A. Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis. Am Surg 2023; 89:2743-2754. [PMID: 36802811 DOI: 10.1177/00031348231157809] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries. METHODS This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days. RESULTS A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)]. CONCLUSIONS In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries. STUDY TYPE Systematic Review and meta-analysis.
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Affiliation(s)
- George Beeton
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Micah Ngatuvai
- Dr Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Tessa Breeding
- Dr Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Ryan Andrade
- A.T. Still University School of Osteopathic Medicine, Mesa, AZ, USA
| | - Ruth Zagales
- Florida International University, Miami, FL, USA
| | - Areeba Khan
- Department of Mathematics, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Radleigh Santos
- Department of Mathematics, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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15
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Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
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16
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Ntola VC, Hardcastle TC. Diagnostic Approaches to Vascular Injury in Polytrauma-A Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13061019. [PMID: 36980328 PMCID: PMC10046960 DOI: 10.3390/diagnostics13061019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Polytrauma is understood as significant injuries, occurring at the same time, to two or more anatomical regions (the ISS regions) or organ systems, with at least one of the injuries considered as posing a threat to life. Trauma is the main cause of unexpected demise in individuals below the age of 44 years and represents a huge burden on society. Vascular injury is highly morbid; it can lead to rapid exsanguination and death, posing a threat to both life and the limb. Independent predictors of outcome include mechanism of injury, associated injuries, and time from injury to definitive care. The mechanisms of vascular injury in the setting of polytrauma are either blunt, penetrating or a combination of the two. METHODS Comprehensive literature review of current diagnostic approaches to traumatic vascular injury in the context of polytrauma. The factors influencing the diagnostic approach are highlighted. The focus is the epidemiology of vascular injury and diagnostic approaches to it in the context of polytrauma. RESULTS Traumatic vascular injuries are associated with limb loss or even death. They are characterised by multiple injuries, the dilemma of the diagnostic approach, timing of intervention and higher risk of limb loss or death. The systematic approach in terms of clinical diagnosis and imaging is crucial in order save life and preserve the limb. The various diagnostic tools to individualise the investigation are discussed. CONCLUSION This paper highlights the significance of timely and appropriate use of diagnostic tools for traumatic vascular trauma to save life and to preserve the limb. The associated injury also plays a crucial role in deciding the imaging modalities. At times, more than one investigation may be required.
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Affiliation(s)
- Vuyolwethu C Ntola
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban 4058, South Africa
- Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
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17
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Krämer S, Graeff P, Lindner S, Walles T, Becker L. [Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]. Zentralbl Chir 2023; 148:67-73. [PMID: 36470289 DOI: 10.1055/a-1972-3352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.
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Affiliation(s)
- Sebastian Krämer
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Pascal Graeff
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sebastian Lindner
- Klinik für Thoraxchirurgie und thorakale Endoskopie, HELIOS Klinikum Erfurt, Erfurt, Deutschland
| | - Thorsten Walles
- Klinik für Herz- und Thoraxchirurgie, Abteilung Thoraxchirurgie, Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät, Magdeburg, Deutschland
| | - Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
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18
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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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19
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McLauchlan NR, Igra NM, Fisher LT, Byrne JP, Beyer CA, Geng Z, Schmulevich D, Brinson MM, Dumas RP, Holena DN, Hynes AM, Rosen CB, Shah AN, Vella MA, Cannon JW. Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial. Trauma Surg Acute Care Open 2023; 8:e001050. [PMID: 36967862 PMCID: PMC10030794 DOI: 10.1136/tsaco-2022-001050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/25/2023] [Indexed: 03/29/2023] Open
Abstract
Objective To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence NA.
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Affiliation(s)
- Nathaniel R McLauchlan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah M Igra
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lydia T Fisher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James P Byrne
- Johns Hopkins Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Carl A Beyer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zhi Geng
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniela Schmulevich
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martha M Brinson
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Allyson M Hynes
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Claire B Rosen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Michael A Vella
- Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy W Cannon
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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The sensitivity of chest X-ray (CXR) for the detection of significant thoracic injury in children exposed to blast. Injury 2022; 54:1292-1296. [PMID: 36539310 DOI: 10.1016/j.injury.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Thoracic trauma is an important cause of morbidity and mortality in children exposed to blast and early recognition of these injuries is vital. While numerous studies have investigated the sensitivity of chest X-ray (CXR) for the detection of chest injury in blunt trauma, none have evaluated its performance in paediatric blast injury. METHODS CXR and Computed Tomography (CT) thorax findings were compared for 105 children who were injured by blast and presented to the UK Role 3 Hospital, Camp Bastion, Helmand Province, during the recent conflict in Afghanistan from 2011 to 2013. CXR performance was evaluated compared to the 'gold standard' of CT for the detection of significant thoracic injuries, defined as pneumothorax, haemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, penetrating fragments and pulmonary contusion or laceration. RESULTS The sensitivity of CXR for the detection of significant injuries was: pneumothorax 43%, haemothorax 40%, contusion 44%, laceration 100%, blast lung 80% and subdermal metallic fragments 75%. CXR missed all cases of diaphragm injury, ≥2 rib fractures, clavicle fracture and pleural effusion, although numbers of each were small. Specificity for CXR injury detection was 94% for contusion and 93% for fragment, and 100% otherwise. The sensitivity and specificity of CXR for identifying an abnormality that would prompt CT imaging was 72% (95% CI 55-85%) and 82% (95% CI 70-90%). CONCLUSIONS CXR has a poor sensitivity for the identification of significant thoracic injury in children exposed to blast. We argue that, given the challenge of clinical assessment of injured children and the potential for serious adverse consequences of missed thoracic injuries, there should be a low threshold for the use of CT chest in the evaluation of children exposed to blast.
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21
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Dreizin D, Nixon B, Hu J, Albert B, Yan C, Yang G, Chen H, Liang Y, Kim N, Jeudy J, Li G, Smith EB, Unberath M. A pilot study of deep learning-based CT volumetry for traumatic hemothorax. Emerg Radiol 2022; 29:995-1002. [PMID: 35971025 PMCID: PMC9649862 DOI: 10.1007/s10140-022-02087-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE We employ nnU-Net, a state-of-the-art self-configuring deep learning-based semantic segmentation method for quantitative visualization of hemothorax (HTX) in trauma patients, and assess performance using a combination of overlap and volume-based metrics. The accuracy of hemothorax volumes for predicting a composite of hemorrhage-related outcomes - massive transfusion (MT) and in-hospital mortality (IHM) not related to traumatic brain injury - is assessed and compared to subjective expert consensus grading by an experienced chest and emergency radiologist. MATERIALS AND METHODS The study included manually labeled admission chest CTs from 77 consecutive adult patients with non-negligible (≥ 50 mL) traumatic HTX between 2016 and 2018 from one trauma center. DL results of ensembled nnU-Net were determined from fivefold cross-validation and compared to individual 2D, 3D, and cascaded 3D nnU-Net results using the Dice similarity coefficient (DSC) and volume similarity index. Pearson's r, intraclass correlation coefficient (ICC), and mean bias were also determined for the best performing model. Manual and automated hemothorax volumes and subjective hemothorax volume grades were analyzed as predictors of MT and IHM using AUC comparison. Volume cut-offs yielding sensitivity or specificity ≥ 90% were determined from ROC analysis. RESULTS Ensembled nnU-Net achieved a mean DSC of 0.75 (SD: ± 0.12), and mean volume similarity of 0.91 (SD: ± 0.10), Pearson r of 0.93, and ICC of 0.92. Mean overmeasurement bias was only 1.7 mL despite a range of manual HTX volumes from 35 to 1503 mL (median: 178 mL). AUC of automated volumes for the composite outcome was 0.74 (95%CI: 0.58-0.91), compared to 0.76 (95%CI: 0.58-0.93) for manual volumes, and 0.76 (95%CI: 0.62-0.90) for consensus expert grading (p = 0.93). Automated volume cut-offs of 77 mL and 334 mL predicted the outcome with 93% sensitivity and 90% specificity respectively. CONCLUSION Automated HTX volumetry had high method validity, yielded interpretable visual results, and had similar performance for the hemorrhage-related outcomes assessed compared to manual volumes and expert consensus grading. The results suggest promising avenues for automated HTX volumetry in research and clinical care.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA.
| | - Bryan Nixon
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jiazhen Hu
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Benjamin Albert
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Chang Yan
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Gary Yang
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Haomin Chen
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Yuanyuan Liang
- Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nahye Kim
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elana B Smith
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
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22
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Freeman JJ, Asfaw SH, Vatsaas CJ, Yorkgitis BK, Haines KL, Burns JB, Kim D, Loomis EA, Kerwin AJ, McDonald A, Agarwal, S, Fox N, Haut ER, Crandall ML, Como JJ, Kasotakis G. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2022; 7:e000886. [PMID: 36312819 PMCID: PMC9608538 DOI: 10.1136/tsaco-2022-000886] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 10/02/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. METHODS Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. DISCUSSION In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO REGISTRATION NUMBER CRD42018088759.
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Affiliation(s)
- Jennifer J Freeman
- Surgery, Texas Christian University Burnett School of Medicine, Fort Worth, Texas, USA
| | - Sofya H Asfaw
- General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cory J Vatsaas
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Krista L Haines
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - J Bracken Burns
- Surgery, East Tennessee State University, Johnson City, Tennessee, USA
| | - Dennis Kim
- Surgical Critical Care, Los Angeles County Harbor–UCLA Medical Center, Torrance, California, USA
| | | | - Andy J Kerwin
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Amy McDonald
- Surgery, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Suresh Agarwal,
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicole Fox
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | | | - Marie L Crandall
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - John J Como
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - George Kasotakis
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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23
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Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy. J Pers Med 2022; 12:jpm12101570. [PMID: 36294709 PMCID: PMC9605043 DOI: 10.3390/jpm12101570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/02/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO2) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.
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Zhang G, Shurtleff E, Falank C, Cullinane D, Carter D, Sheppard F. Thoracoscopic-assisted rib plating (TARP): initial single-center case series, including TARP in the super elderly, technical lessons learned, and proposed expanded indications. Trauma Surg Acute Care Open 2022; 7:e000943. [PMID: 36111139 PMCID: PMC9438051 DOI: 10.1136/tsaco-2022-000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022] Open
Abstract
Objectives The application of surgical stabilization of rib fractures (SSRF) remains inconsistent due to evolving indications and perceived associated morbidity. By implementing thoracoscopic-assisted rib plating (TARP), a minimally invasive SSRF approach, we expanded our SSRF application to patients who otherwise might not be offered fixation. This report presents our initial experience, including fixation in super elderly (aged ≥85 years), and technical lessons learned. Methods This was a retrospective cohort study at a level 1 trauma center of admitted patients who underwent TARP between August 2019 and October 2020. Patient demographics, injury characteristics, surgical indications and outcomes are represented as mean±SD, median or percentage. Results A total of 2134 patients with rib fractures were admitted. In this group, 39 SSRF procedures were performed, of which 54% (n=21) were TARP. Average age was 68.5±16 years. Patients had a median of 5 fractured ribs, with an average of 1 rib that was bicortically displaced, and 19% presented with ‘clicking’ on inspiration. Patient outcomes were a mean hospital length of stay (LOS) of 11±3.7 days, mean postoperative LOS of 8 days, and mean intensive care unit LOS of 6.6±2.9 days. Five patients were ≥85 years old with a mean age of 90.8±4.7 years. They presented with an average of 4 rib fractures, of which an average of 2.4 ribs were plated. The procedure was well tolerated in this age group with a hospital LOS of 9.4±2 days, and all five patients were discharged to a rehab facility with no in-hospital mortalities. Conclusion Our experience incorporating TARP at our institution demonstrated feasibility of the technique and application across a broad range of patients. This approach and its application warrants further evaluation and potentially expands the application of SSRF. .
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Affiliation(s)
- Gary Zhang
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
| | - Eric Shurtleff
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
| | - Daniel Cullinane
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
| | - Damien Carter
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
| | - Forest Sheppard
- Department of Surgery, Maine Medical Center, Portland, Maine, USA
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25
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Janowak CF, Becker BR, Philpott CD, Makley AT, Mueller EW, Droege CA, Droege ME. Retrospective Evaluation of Intrapleural Tissue Plasminogen Activator With or Without Dornase Alfa for the Treatment of Traumatic Retained Hemothorax: A 6-Year Experience. Ann Pharmacother 2022; 56:10600280221077383. [PMID: 35184602 DOI: 10.1177/10600280221077383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intrapleural fibrinolytic instillation is second-line treatment for retained hemothorax. Dornase alfa (DNase) has demonstrated efficacy in parapneumonic effusion, but the lack of deoxyribonucleoproteins limits direct extrapolation to traumatic retained hemothorax treatment. OBJECTIVE This study evaluated the effectiveness of intrapleural tissue plasminogen activator (tPA) with and without DNase in the treatment of retained traumatic hemothorax. METHODS This retrospective cohort study included patients aged 16 years and older admitted to a level 1 trauma center from January 2013 through July 2019 with retained hemothorax and one or more intrapleural tPA instillations. Exclusion criteria were tPA for other indications or concomitant empyema. The primary endpoint was treatment failure defined as the need for operative intervention. RESULTS Fifty patients were included (tPA alone: 28; tPA with DNase: 22). Baseline characteristics were similar between groups, including time to diagnosis (6.5 [interquartile range (IQR), 4-15.5] days vs 6 [IQR, 6.3-10.8] days, P = 0.52). Median tPA dose per treatment (6 [IQR, 6-6.4] mg vs 10 [IQR, 8.4-10] mg, P < 0.001) and cumulative tPA (18 [IQR, 6.5-24] mg vs 30 [IQR, 29.5-40], P < 0.001) dose were significantly lower in the tPA alone group. Treatment failure was similar between groups. Chest tube output, retained hemothorax reduction, and bleeding incidences were similar between groups. Multivariate logistic regression demonstrated no significant risk factors for treatment failure. CONCLUSIONS AND RELEVANCE Dornase alfa added to tPA may not reduce the need for operation to treat retained hemothorax. Further studies should be directed at optimal tPA dose determination and economic impact of inappropriate DNase use.
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Affiliation(s)
- Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bradley Robert Becker
- IngenioRX, Inc, Morristown, NJ, USA
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Carolyn Dosen Philpott
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amy Teres Makley
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric William Mueller
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Christopher Allen Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Molly Elizabeth Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
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Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes. Eur J Trauma Emerg Surg 2022; 48:3211-3219. [PMID: 35084506 DOI: 10.1007/s00068-022-01881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. METHOD We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. RESULTS Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. CONCLUSION Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.
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Use of Intrapleural Fibrinolytic Therapy in a Trapped Lung following Acute Traumatic Haemothorax. Case Rep Pulmonol 2021; 2021:5592086. [PMID: 34239751 PMCID: PMC8238625 DOI: 10.1155/2021/5592086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/11/2021] [Indexed: 11/18/2022] Open
Abstract
Retained haemothorax is a common sequela of traumatic haemothorax and refers to blood that cannot be drained from the pleural cavity. We report a case of trapped lung secondary to retained haemothorax in a patient who sustained a penetrating chest injury. Initial chest computed tomography (CT) showed a large haemothorax that was managed with an intercostal drain insertion (ICD). Repeat chest CT and thoracic ultrasonography performed after ICD removal showed an organized pleural space resembling haematoma. ICD was reinserted with administration of intrapleural fibrinolytic therapy (IPFT). Subsequent chest CT showed the development of a pleural rind and trapped lung. A second ICD was inserted, and further IPFT were administered together with aggressive negative pressure suction. Haemoglobin remained stable. The patient made a full recovery and imaging performed two weeks later showed minor blunting of the costophrenic angle. This case highlights the feasibility and safety of IPFT in the management of trapped lung associated with traumatic retained haemothorax as an alternative to surgery.
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28
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Patel NJ, Dultz L, Ladhani HA, Cullinane DC, Klein E, McNickle AG, Bugaev N, Fraser DR, Kartiko S, Dodgion C, Pappas PA, Kim D, Cantrell S, Como JJ, Kasotakis G. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2021; 221:873-884. [DOI: 10.1016/j.amjsurg.2020.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
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Lohan R, Leow KS, Ong MW, Goo TT, Punamiya S. Role of Intercostal Artery Embolization in Management of Traumatic Hemothorax. J Emerg Trauma Shock 2021; 14:111-116. [PMID: 34321811 PMCID: PMC8312918 DOI: 10.4103/jets.jets_157_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/07/2021] [Accepted: 02/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.
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Affiliation(s)
- Rahul Lohan
- Departments of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Kheng Song Leow
- Department of Diagnostic Radiology, Woodlands Health Campus, Singapore 768024, Singapore
| | - Marc Weijie Ong
- Departments of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Tiong Thye Goo
- Departments of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Sundeep Punamiya
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Radiomics score predicts acute respiratory distress syndrome based on the initial CT scan after trauma. Eur Radiol 2021; 31:5443-5453. [PMID: 33733689 PMCID: PMC8270830 DOI: 10.1007/s00330-020-07635-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/02/2020] [Accepted: 12/16/2020] [Indexed: 12/26/2022]
Abstract
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.
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31
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Huang JF, Hsu CP, Fu CY, Ou Yang CH, Cheng CT, Liao CH, Kuo IM, Hsieh CH. Is massive hemothorax still an absolute indication for operation in blunt trauma? Injury 2021; 52:225-230. [PMID: 33386159 DOI: 10.1016/j.injury.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery. METHODS Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared. RESULTS Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels. CONCLUSION Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.
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Affiliation(s)
- Jen-Fu Huang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan.
| | - Chun-Hsiang Ou Yang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chien-Hung Liao
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - I-Ming Kuo
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chi-Hsun Hsieh
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
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Bauman ZM, Kulvatunyou N, Joseph B, Gries L, O'Keeffe T, Tang AL, Rhee P. Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax. World J Surg 2021; 45:880-886. [PMID: 33415448 PMCID: PMC7790482 DOI: 10.1007/s00268-020-05852-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/01/2022]
Abstract
Introduction Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. Methods Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05. Results Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P = 0.001). Conclusion In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434
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Affiliation(s)
- Zachary M Bauman
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska, Omaha, NE, USA
| | - Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245063, Tucson, AZ, 85724-5063, USA.
| | - Bellal Joseph
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245063, Tucson, AZ, 85724-5063, USA
| | - Lynn Gries
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245063, Tucson, AZ, 85724-5063, USA
| | - Terence O'Keeffe
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245063, Tucson, AZ, 85724-5063, USA
| | - Andrew L Tang
- Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245063, Tucson, AZ, 85724-5063, USA
| | - Peter Rhee
- Department of Surgery, New York Medical College, Valhalla, NY, USA
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Donaldson RI, Zimmermann EM, Buchanan OJ, Graham TL, Ross JD. Efficacy of a novel chest tube system in a swine model of hemothorax. J Thorac Dis 2021; 13:213-219. [PMID: 33569201 PMCID: PMC7867831 DOI: 10.21037/jtd-20-1609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tube thoracostomy is the definitive treatment for most significant chest trauma, including injuries resulting in pneumothorax, hemothorax, and hemopneumothorax. However, traditional chest tubes fail to sufficiently remove blood up to 20% of the time (i.e., retained hemothorax), which can lead to empyema and fibrothorax, as well as significant morbidity and mortality. Here we describe the use of a novel chest tube system in a swine model of hemothorax. Methods This was an intra-animal-paired, randomized-controlled study of hemothorax evacuation using the PleuraPath™ Thoracostomy System (PPTS) compared to a traditional chest tube in large Yorkshire-Landrace swine (75–85 kg). One liter of autologous whole blood was infused into each pleural cavity simultaneously with subsequent drainage from each device individually monitored for a total of 120 minutes, before the end of the experiment and necroscopy. Results Six animals completed the full protocol. On average, the PPTS removed 17% more blood (P=0.049) and left 19.1% less residual hemothorax (P=0.023) as compared to the standard of care during the first two hours of use. No complications or iatrogenic injury were identified in any animal for either device. Conclusions The novel PPTS device was superior to the traditional chest tube drainage system in this acute, large-animal model of retained hemothorax. While this study supports clinical translation, further research will be required to assess efficacy and optimize device use in humans.
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Affiliation(s)
- Ross I Donaldson
- Critical Innovations, Los Angeles, CA, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Department of Epidemiology, UCLA-Fielding School of Public Health, Los Angeles, CA, USA
| | - Eric M Zimmermann
- Department of Surgery, Oregon Health & Science University School of Medicine, Portland, OR, USA.,Department of Surgery, New York Presbyterian Queens, New York City, NY, USA
| | | | - Todd L Graham
- Department of Surgery, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - James D Ross
- Department of Surgery, Oregon Health & Science University School of Medicine, Portland, OR, USA.,Charles T Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, USA
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Weaver JL, Kaufman EJ, Young AJ, Keating JJ, Subramanian M, Cannon JW, Shiroff A, Seamon MJ. Outcomes in Delayed Drainage of Hemothorax. Am Surg 2020; 87:1140-1144. [PMID: 33342278 DOI: 10.1177/0003134820956343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Prompt drainage of traumatic hemothorax is recommended to prevent empyema and trapped lung. Some patients do not present the day of their trauma, leading to their delayed treatment. Delayed drainage could be challenging as clotted blood may not evacuate through a standard chest tube. We hypothesized that such delays would increase the need for surgery or secondary interventions. METHODS Our trauma registry was reviewed for patients with a hemothorax admitted to our level 1 trauma center from 1/1/00 to 4/30/19. Patients were included in the delayed group if they received a drainage procedure >24 hours after injury. These patients were matched 1:1 by chest abbreviated injury score to patients who received drainage <24 hours from injury. RESULTS A total of 19 patients with 22 hemothoraces received delayed drainage. All but 3 patients had a chest tube placed as initial treatment. Four patients received surgery, including 3 who initially had chest tubes placed. Longer time to drainage increased the odds of requiring intrathoracic thrombolytics or surgery. In comparison, 2 patients who received prompt drainage received thrombolytics (P = .11) and none required surgery (P = .02). Patients needed surgery when initial drainage was on or after post-injury day 5, but pigtail catheter drainage was effective 26 days after injury. DISCUSSION Longer times from injury to intervention are associated with increased likelihood of needing surgery for hemothorax evacuation, but outcomes were not uniform. A larger, multicenter study will be necessary to provide better characterization of treatment outcomes for these patients.
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Affiliation(s)
- Jessica L Weaver
- University of California San Diego Division of Trauma, Surgical Critical Care, Burn, and Acute Care Surgery, San Diego, CA, USA
| | - Elinore J Kaufman
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Andrew J Young
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Jane J Keating
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Madhu Subramanian
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Jeremy W Cannon
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Adam Shiroff
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
| | - Mark J Seamon
- University of Pennsylvania Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Philadelphia, PA, USA
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Makey IA, Das NA, Jacob S, El-Sayed Ahmed MM, Makey CM, Johnson SB, Thomas M. Agitation Techniques to Enhance Drainage of Retained Hemothorax. Surg Innov 2020; 28:544-551. [PMID: 33339490 DOI: 10.1177/1553350620978002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Retained hemothorax (RH) is a common problem in cardiothoracic and trauma surgery. We aimed to determine the optimum agitation technique to enhance thrombus dissolution and drainage and to apply the technique to a porcine-retained hemothorax. Methods. Three agitation techniques were tested: flush irrigation, ultrasound, and vibration. We used the techniques in a benchtop model with tissue plasminogen activator (tPA) and pig hemothorax with tPA. We used the most promising technique vibration in a pig hemothorax without tPA. Statistics. We used 2-sample t tests for each comparison and Cohen d tests to calculate effect size (ES). Results. In the benchtop model, mean drainages in the agitation group and control group and the ES were flush irrigation, 42%, 28%, and 2.91 (P = .10); ultrasound, 35%, 27%, and .76 (P = .30); and vibration, 28%, 19%, and 1.14 (P = .04). In the pig hemothorax with tPA, mean drainages and the ES of each agitation technique compared with control (58%) were flush irrigation, 80% and 1.14 (P = .37); ultrasound, 80% and 2.11 (P = .17); and vibration, 95% and 3.98 (P = .06). In the pig hemothorax model without tPA, mean drainages of the vibration technique and control group were 50% and 43% (ES = .29; P = .65). Discussion. In vitro studies suggested flush irrigation had the greatest effect, whereas only vibration was significantly different vs the respective controls. In vivo with tPA, vibration showed promising but not statistically significant results. Results of in vivo experiments without tPA were negative. Conclusion. Agitation techniques, in combination with tPA, may enhance drainage of hemothorax.
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Affiliation(s)
- Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | | | | | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
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Laugsand EA, Xanthoulis A. Management of a life-threatening intercostal artery bleeding, difficult to visualize in open surgery: a case report. J Surg Case Rep 2020; 2020:rjaa444. [PMID: 33154815 PMCID: PMC7602520 DOI: 10.1093/jscr/rjaa444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Life-threatening bleeding from an intercostal artery is a rare and challenging event. A 74-year-old patient with a right-sided pleural effusion was treated by a pigtail pleural drain. He developed a large haemothorax, initially addressed by a large bore chest tube. As he became haemodynamically unstable, he required an emergency anterolateral right thoracotomy. It was difficult to visualize and reach the bleeding vessel during open surgery. A 30° laparoscopy camera was introduced and the bleeding site was identified. An incision was made directly over the bleeding site and the two ends of the lacerated intercostal artery were ligated by two externally placed figure-of-eight sutures. The patient survived and recovered fully. As most general surgeons, even at smaller hospitals, are familiar with laparoscopy, the technique described here may be useful for other surgeons to employ if a life-threatening intercostal artery injury occurs.
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Affiliation(s)
- Eivor Alette Laugsand
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Athanasios Xanthoulis
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031. [PMID: 32702777 PMCID: PMC7390330 DOI: 10.1002/14651858.cd013031.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes. OBJECTIVES To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy. SEARCH METHODS We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed. SELECTION CRITERIA We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non-radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta-analyses by using a bivariate model to estimate and compare summary sensitivities and specificities. MAIN RESULTS We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax. AUTHORS' CONCLUSIONS The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.
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Affiliation(s)
- Kenneth K Chan
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Daniel A Joo
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zahra A Premji
- Libraries and Cultural Resources, University of Calgary, Calgary, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Abel Wakai
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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Haut ER. Eastern Association for the Surgery of Trauma (EAST) practice management guidelines and the perpetual quest for excellence. J Trauma Acute Care Surg 2020; 89:1-10. [PMID: 32251261 DOI: 10.1097/ta.0000000000002709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery, Department of Anesthesiology and Critical Care Medicine, and Department of Emergency Medicine, Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Scott TE, Haque M, Das A, Cliff I, Bates DG, Hardman JG. Efficacy of continuous positive airway pressure in casualties suffering from primary blast lung injury: A modeling study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:4965-4968. [PMID: 31946974 DOI: 10.1109/embc.2019.8857613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Primary blast lung injury is the most important component of a multisystem syndrome of injury that results from exposure to an explosive shockwave. The majority of such casualties require ventilation in an intensive care unit. We describe the use of a novel primary blast lung injury simulator to evaluate the potential efficacy of continuous positive airway pressure in 6 in silico casualties over 24 hours after injury. Our results suggest that primary blast lung injury is a form of acute lung injury that can be effectively managed with continuous positive airway pressure. In austere environments or in circumstances where medical resources are overwhelmed, continuous positive airway pressure using ambient air may be of benefit.
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40
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Kim M, Moore JE. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:61-68. [PMID: 32435162 PMCID: PMC7223697 DOI: 10.1007/s40140-020-00374-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose of Review This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury. Recent Findings Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described. Summary Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.
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Affiliation(s)
- Michelle Kim
- 1University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, MD USA
| | - James E Moore
- 2Consultant Anaesthetist, Intensive Care Physician & Director of Trauma Services, Wellington Hospital, Wellington, New Zealand
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Gonzalez G, Robert C, Petit L, Biais M, Carrié C. May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients? Eur J Trauma Emerg Surg 2020; 47:71-78. [PMID: 32435842 DOI: 10.1007/s00068-020-01391-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess the impact of delayed hemothorax on outcomes in blunt chest trauma patients without life-threatening condition at admission and characterize the predictive value of predefined anatomical factors for delayed hemothorax. METHODS In a single-centre retrospective study, every spontaneous breathing patient admitted for a blunt chest trauma without significant pleural effusion at ICU admission was included. A multivariable regression model was used to determine the covariate-adjusted odd of secondary respiratory complications in patients with delayed hemothorax ≥ 500 ml. The characteristics of rib fractures (number, location and displacement) were integrated into a logistic regression model to determine variables associated with delayed hemothorax in multivariate analysis. RESULTS Over the study period, 109 patients were included and the rate of delayed hemothorax ≥ 500 ml was 36%. Patients with delayed hemothorax had higher rates of pulmonary infections (OR 4.8 [1.6-16.4]) but no statistical association between delayed hemothorax and secondary respiratory failure (OR 2.0 [0.4-9.4]). A posterior location and a displaced rib fracture were independent predictors of delayed hemothorax (OR 3.4 [1.3-8.6] and OR 2.3 [1.1-5.1], respectively). At least one displaced rib fracture was more specific of delayed hemothorax than the commonly used threshold of three or more rib fractures (81.3 vs. 51.5%). CONCLUSION Delayed hemothorax is a frequent complication associated with increased risk of pulmonary infection. The posterior location and the displacement of at least one rib fracture in the initial CT scan were independent risk factors for predicting the occurrence of delayed hemothorax.
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Affiliation(s)
- Geoffrey Gonzalez
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France.
| | - Charlotte Robert
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Laurent Petit
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Matthieu Biais
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France.,University of Bordeaux, Segalen, 33000, Bordeaux, France
| | - Cédric Carrié
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
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Correa Restrepo J, Restrepo-Moreno M, Peláez LG, Díaz Cadavid RD, López-Vasco Y, Alejandra Rojas M, Mejía Toro DA, Morales Uribe CH. Radiografía de tórax de control en pacientes con neumotórax postraumático asintomático. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El trauma de tórax tiene alta incidencia y el neumotórax es el hallazgo más frecuente. La literatura es escasa sobre qué hacer con los pacientes asintomáticos y con neumotórax por trauma de tórax penetrante.
El objetivo de este estudio fue evaluar cuáles son los hallazgos de la radiografía de control de los pacientes con trauma de tórax penetrante que no son llevados inicialmente a cirugía, y su utilidad para determinar la necesidad de un tratamiento adicional.
Métodos. Se realizó un estudio retrospectivo de cohorte, incluyendo pacientes mayores de 15 años que ingresaron por trauma de tórax penetrante entre enero de 2015 y diciembre de 2017 y que no requirieron manejo quirúrgico inicial. Se analizaron los resultados de la radiografía de tórax, el tiempo de su toma y la conducta decidida según los hallazgos en los pacientes dejados inicialmente bajo observación.
Resultados. Se incluyeron 1.554 pacientes, cuya edad promedio fue de 30 años, 92,5 % del sexo masculino y 97% con herida por arma cortopunzante. Se dejaron 361 pacientes bajo observación con radiografía de control, de los cuales 186 (51,5 %) no presentaban alteraciones en su radiografía inicial, 142 tenían neumotórax menor del 30 % y 33 tenían neumotórax mayor del 30 %, hemoneumotórax o hemotórax. Se requirió toracostomía cerrada como conducta final en 78 casos, esternotomía o toracotomía en 2 casos y 281 se dieron de alta.
Conclusión. En pacientes asintomáticos con neumotórax pequeño o moderado y sin otras lesiones significativas, podrían ser innecesarios los largos tiempos de observación, las radiografías y la toracostomía cerrada.
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Mahmood I, Younis B, Ahmed K, Mustafa F, El-Menyar A, Alabdallat M, Parchani A, Peralta R, Nabir S, Ahmed N, Al-Thani H. Occult Pneumothorax in Patients Presenting with Blunt Chest Trauma: An Observational Analysis. Qatar Med J 2020; 2020:10. [PMID: 32206592 PMCID: PMC7075257 DOI: 10.5339/qmj.2020.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/21/2019] [Indexed: 12/02/2022] Open
Abstract
Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammad Alabdallat
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Parchani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Syed Nabir
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Nadeem Ahmed
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
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Critical Care Ultrasound Should Be a Priority First-Line Assessment Tool in Neurocritical Care. Crit Care Med 2020; 47:833-836. [PMID: 30870190 DOI: 10.1097/ccm.0000000000003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tignanelli CJ, Rix A, Napolitano LM, Hemmila MR, Ma S, Kummerfeld E. Association Between Adherence to Evidence-Based Practices for Treatment of Patients With Traumatic Rib Fractures and Mortality Rates Among US Trauma Centers. JAMA Netw Open 2020; 3:e201316. [PMID: 32215632 PMCID: PMC7707110 DOI: 10.1001/jamanetworkopen.2020.1316] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Rib fractures are sustained by nearly 15% of patients who experience trauma and are associated with significant morbidity and mortality. Evidence-based practice (EBP) rib fracture management guidelines and treatment algorithms have been published. However, few studies have evaluated trauma center adherence to EBP or the clinical outcomes of each practice within a national cohort. OBJECTIVE To examine adherence to 6 EBPs for rib fractures across US trauma centers and the association with in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from January 1, 2007, to December 31, 2014, of 777 US trauma centers participating in the National Trauma Data Bank. A total of 625 617 patients (age, ≥16 years) were evaluated. Patients without rib fractures and those with no signs of life or institutions with poor data quality were excluded. Data analysis was performed from January 1, 2007, to December 31, 2014. MAIN OUTCOMES AND MEASURES Six EBPs were defined: (1) neuraxial blockade, (2) intensive care unit admission, (3) pneumatic stabilization, (4) chest computed tomographic scans for older adults (≥65 years) with 3 or more rib fractures, (5) surgical rib fixation for flail chest, and (6) tube thoracostomy placement for hemothorax and/or pneumothorax. Multiple imputation was used to account for missing data. Patients were propensity score matched in a 1:1 fashion based on demographic characteristics; injury severity parameters, including the Injury Severity Score (range, 0-75; higher scores indicate more severe injuries); and comorbidities. Logistic regression was used to determine the association of each practice with all-cause in-hospital mortality. RESULTS Of the 625 617 patients with rib fractures included in this analysis, 456 196 patients (73%) were white and 432 229 patients (69%) were male; the median age of the patients was 51 (interquartile range, 37-65) years, and the mean (SD) Injury Severity Score was 18.3 (11.1). The mean (SD) number of rib fractures was 4.2 (2.6). On univariate analysis, patients treated at verified level I trauma centers were more likely to receive 5 or 6 EBPs (all but pneumatic stabilization). Of those who met eligibility, only 4578 of 111 589 patients (4%) received neuraxial blockade, 46 456 of 111 589 patients (42%) were admitted to the intensive care unit, 3302 of 24 319 patients (14%) received surgical rib fixation, 1240 of 111 589 patients (1%) received pneumatic stabilization, 109 160 of 258 334 patients (42%) received tube thoracostomy, and 32 405 of 81 417 patients (40%) received chest computed tomographic scans. Three EBPs were associated with decreased mortality: neuraxial blockade (odds ratio [OR], 0.64; 95% CI, 0.51-0.79; P < .001) for patients aged 65 years or older with 3 or more rib fractures, surgical rib fixation (OR, 0.13; 95% CI, 0.01-0.18; P < .001), and intensive care unit admission (OR, 0.93; 95% CI, 0.86-1.00; P = .04) for patients aged 65 years or older with 3 or more rib fractures. Pneumatic stabilization (OR, 1.71; 95% CI, 1.25-2.35; P < .001) and chest tube placement (OR, 1.27; 95% CI, 1.21-1.33; P < .001) were associated with increased mortality in older patients with 3 or more rib fractures. On multivariable analysis, insurance status, race/ethnicity, injury severity, hospital bed size, and trauma center verification level were associated with receiving EBPs for rib fractures. CONCLUSIONS AND RELEVANCE Significant variation appears to exist in the delivery of EBPs for rib fractures across US trauma centers. Three EBPs were associated with reduced mortality, but EBP adherence was poor. Multiple factors, including trauma center verification level, appear to be associated with patients receiving EBPs for rib fractures.
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Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | - Alexander Rix
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | | | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor
| | - Sisi Ma
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
| | - Erich Kummerfeld
- Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Stab Wound to the Chest. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ziapour B, Mostafidi E, Sadeghi-Bazargani H, Kabir A, Okereke I. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg 2019; 46:337-346. [PMID: 31848631 DOI: 10.1007/s00068-019-01275-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE In this systematic review, we analyzed the optimal time range to evacuate traumatic-retained hemothorax using video-assisted thoracoscopic surgery (VATS). METHODS We searched PubMed, EMBASE, the Cochrane Register of Controlled Trials, Google Scholar, and the U.S. National Library of Medicine clinical trials database up to February 2019. Randomized controlled trials (RCTs) and observational studies with relevant data were included. Data were extracted from studies that reported the success, mortality, or length of hospital stay (LOS) after using VATS during at least two out of three of our time-ranges of interest: days 1-3 (group A), days 4-6 (group B), and day 7 or later (group C). RESULTS Six cohort studies with 476 total participants were included in the meta-analysis. The patients in group A had a significantly higher success rate than those in group C (RR = 0.42; 95% CI = 0.21-0.84, p = 0.01). The total LOS for patients whose retained hemothorax was evacuated in group A was 4.7 days shorter than that for those in group B (95% CI = - 5.6 to - 3.8, p = 0.006). Likewise, group B patients were discharged 18.1 days earlier than group C patients (95% CI = - 22.3 to - 14, p < 0.001). Short-term mortality was not decreased by early VATS. CONCLUSIONS Our results indicate that VATS should be considered within the first three days of admission if this intervention is the clinician's choice to evacuate a traumatic-retained hemothorax. Protocol registration number in PROSPERO: CRD42017046856.
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Affiliation(s)
- Behrad Ziapour
- Tufts Medical Center, 800 Washington Street #1035, Boston, MA, 02111, USA.
| | | | - Homayoun Sadeghi-Bazargani
- Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ikenna Okereke
- Chief of Thoracic Surgery, Division of Cardiovascular and Thoracic Surgery, Program Director, Cardiothoracic Fellowship Program, Division of Cardiothoracic Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0528, USA
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Cook A, Hu C, Ward J, Schultz S, Moore Iii FO, Funk G, Juern J, Turay D, Ahmad S, Pieri P, Allen S, Berne J. Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study. Trauma Surg Acute Care Open 2019; 4:e000356. [PMID: 31799417 PMCID: PMC6861092 DOI: 10.1136/tsaco-2019-000356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022] Open
Abstract
Background Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement. Methods The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively. Results TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53). Conclusion There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship. Level of evidence II Prospective comparative study
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Affiliation(s)
- Alan Cook
- Department of Surgery, University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | - Chengcheng Hu
- Department of Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA
| | - Jeanette Ward
- Department of Trauma, HonorHealth, Scottsdale, Arizona, USA
| | - Susan Schultz
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | | | - Geoffrey Funk
- Department of Surgery, Baylor Scott and White Health, Dallas, Texas, USA
| | - Jeremy Juern
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Turay
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
| | - Salman Ahmad
- Department of Surgery, University of Missouri Hospital & Clinics, Columbia, Missouri, USA
| | - Paola Pieri
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona, USA
| | - Steven Allen
- Department of Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John Berne
- Department of Surgery, Broward Health, Fort Lauderdale, Florida, USA
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Holsen MR, Tameron AM, Evans DC, Thompson M. Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax. Ann Pharmacother 2019; 53:1060-1066. [DOI: 10.1177/1060028019846122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax.
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Affiliation(s)
- Maya R. Holsen
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - David C. Evans
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Molly Thompson
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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