The Clinical Significance of Occult Thoracic Injury in Blunt Trauma Patients

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed “occult injury.” The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: 1) no injury (normal CXR, normal TCT, n = 1337); 2) occult injury (normal CXR, abnormal TCT, n = 205); and 3) overt injury (abnormal CXR, abnormal TCT, n = 227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.

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Injuries to the Chest Part 1

10.2310/vasc.2133 ◽

2019 ◽

Author(s):

Erika B. Call ◽

Amy N. Hildreth ◽

J. Jason Hoth

Keyword(s):

Emergency Department ◽

Injury Severity ◽

Flail Chest ◽

Rib Fractures ◽

Pulmonary Contusion ◽

Thoracic Injury ◽

Resuscitative Thoracotomy ◽

Pulmonary Laceration ◽

Tracheobronchial Injury ◽

Early Trauma

Thoracic injury is common and is associated with significant morbidity and mortality. Injuries to the chest are responsible for 25% of blunt trauma fatalities and contribute to an additional 50% of deaths in this population.1 Fortunately, the majority of thoracic injuries can be treated effectively, and often definitively, by relatively simple maneuvers that can be learned and performed by most physicians involved in early trauma care. Only 5 to 10% will require operative intervention.2 These extremes in injury severity are unique to the chest and require treatment by a surgeon with a correspondingly broad range of knowledge and skills. This article will address the following procedures and injuries: tube thoracostomy, thoracotomy, emergency department resuscitative thoracotomy, video-assisted thoracoscopy, chest wall injuries including rib fractures and flail chest, pneumothorax, hemothorax, empyema, pulmonary contusion and laceration, and tracheobronchial injury. This review 6 figures, 1 table, and 49 references. Keywords: Tube thoracoscopy, emergency department resuscitative thoracotomy (EDRT), rib fractures, flail chest, pneumothorax, hemothorax, empyema, pulmonary contusion, pulmonary laceration, tracheobronchial injury

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08. Missed Diagnosis of Pneumothorax During Aeromedical Transport

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00045829 ◽

1996 ◽

Vol 11 (S2) ◽

pp. S38-S38

Author(s):

SH Thomas ◽

P DeVellis ◽

T Harrison ◽

SK Wedel

Keyword(s):

Trauma Center ◽

Air Transport ◽

Trauma Patients ◽

X Ray ◽

Chest X Ray ◽

Missed Diagnosis ◽

Level I ◽

Aeromedical Transport ◽

One Year ◽

Needle Decompression

Purpose: Difficulties with physical assessment inherent to the helicopter environment have led to suggestion that aeromedical crews may be unable to identify hemo- or pneumothorax (HTX/PTX) while in-flight. This study was conducted to determine the frequency of missed HTX/PTX in trauma patients undergoing air transport.Methods: One year (1994) of an air medical service's trauma transports to a Level I trauma center were analyzed to identify patients undergoing tube thoracostomy (TT) within 2 hours of trauma center arrival. Patients who had received intra-transport needle thoracostomy were excluded. Records were reviewed to determine how HTX/PTX was diagnosed at the trauma center.Results: Only 11 patients who had not received aeromedical needle decompression underwent TT at the receiving center. Two of the 11 were trauma arrests and received TT as part of thoracotomy, without air or blood return on TT. None of the remaining 9 patients had TT on clinical suspicion alone. Four had normal physical examination and underwent TT after chest X-ray (CXR). Remaining patients had no HTX/PTX clues on exam or CXR; one had a small HTX identified on chest computed tomography and the other four received intra-operative TT because of rib fractures in the setting of multisystem trauma.

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Optimizing Chest X-ray Indication in Blunt Trauma Patients using Clinical Criteria

Panamerican Journal of Trauma, Critical Care & Emergency Surgery ◽

10.5005/jp-journals-10030-1169 ◽

2017 ◽

Vol 6 (1) ◽

pp. 30-34

Author(s):

Luca GA Pivetta ◽

Cristiano Below ◽

Giovanna Z Rondini ◽

Jacqueline AG Perlingero ◽

José C Assef ◽

...

Keyword(s):

Blunt Trauma ◽

Thoracic Injury ◽

Trauma Patients ◽

X Rays ◽

Chest Drainage ◽

X Ray ◽

Clinical Criteria ◽

Chest X Ray ◽

Low Probability ◽

Excessive Number

ABSTRACT Background There is an excessive number of unnecessary chest X-rays (CXRs) in minor blunt trauma patients. Objective To identify, using routine clinical criteria, a subgroup of blunt trauma patients that do not require CXR for assessment. Materials and methods This was a retrospective analysis of trauma registry data collected over a 24-month period. Adult blunt trauma patients undergoing CXR on admission were analyzed. The following clinical criteria were assessed: Normal neurologic examination on admission (NNEx), hemodynamic stability (HS), normal physical examination of the chest on admission (NCEx), age ≤ 60 years, and absence of distracting injuries (Abbreviated Injury Scale >2 in head, abdomen, and extremities). These clinical criteria were progressively merged to select a group with lowest risk of exhibiting abnormal CXR on admission. Results Out of 4,647 patients submitted to CXR on admission, 268 (5.7%) had abnormal findings on scans. Of 2,897 patients admitted with NNEx, 116 (4.0%) had abnormal CXR. Of 2,426 patients with NNEx and HS, 74 (3.0%) had abnormal CXR. Of 1,698 patients with NNEx, HS, and NCEx, 24 (1.4%) had abnormal CXR. Of 1,347 patients with NNEx, HS, NCEx, and age < 60 years, 12 had thoracic injury (0.9% of total individuals receiving CXR). A total of 4 patients underwent chest drainage. Among 1,140 cases with all clinical criteria, 8 had confirmed thoracic injuries and 2 underwent chest drainage. Conclusion A subgroup of blunt trauma patients with low probability of exhibiting abnormalities on CXR at admission was identified. The need for CXR in this subgroup should be reviewed. How to cite this article Pivetta LGA, Parreira JG, Below C, Rondini GZ, Perlingero JAG, Assef JC. Optimizing Chest X-ray Indication in Blunt Trauma Patients using Clinical Criteria. Panam J Trauma Crit Care Emerg Surg 2017;6(1):30-34.

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Injuries to the Chest Part 1

DeckerMed Surgery ◽

10.2310/surg.2133 ◽

2019 ◽

Author(s):

Erika B. Call ◽

Amy N. Hildreth ◽

J. Jason Hoth

Keyword(s):

Emergency Department ◽

Injury Severity ◽

Flail Chest ◽

Rib Fractures ◽

Pulmonary Contusion ◽

Thoracic Injury ◽

Resuscitative Thoracotomy ◽

Pulmonary Laceration ◽

Tracheobronchial Injury ◽

Early Trauma

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Predictive Factors of Ventilatory Support in Chest Trauma

Life ◽

10.3390/life11111154 ◽

2021 ◽

Vol 11 (11) ◽

pp. 1154

Author(s):

Silvia Fattori ◽

Elisa Reitano ◽

Osvaldo Chiara ◽

Stefania Cimbanassi

Keyword(s):

Predictive Factors ◽

Thoracic Trauma ◽

Univariate Analysis ◽

Ventilatory Support ◽

Rib Fractures ◽

Pulmonary Contusion ◽

Thoracic Injury ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

This study aims to define possible predictors of the need of invasive and non-invasive ventilatory support, in addition to predictors of mortality in patients with severe thoracic trauma. Data from 832 patients admitted to our trauma center were collected from 2010 to 2017 and retrospectively analyzed. Demographic data, type of respiratory assistance, chest injuries, trauma scores and outcome were considered. Univariate analysis was performed, and binary logistic regression was applied to significant data. The injury severity score (ISS) and the revised trauma score (RTS) were both found to be predictive factors for invasive ventilation. Multivariate analysis of the anatomical injuries revealed that the association of high-severity thoracic injuries with trauma in other districts is an indicator of the need for orotracheal intubation. From the analysis of physiological parameters, values of systolic blood pressure, lactate, and Glasgow coma scale (GCS) score indicate the need for invasive ventilatory support. Predictive factors for non-invasive ventilation include: RTS, ISS, number of rib fractures and presence of hemothorax. Risk factors for death were: age over 65, the presence of bilateral rib fractures, pulmonary contusion, hemothorax and associated head trauma. In conclusion, the need for invasive ventilatory support in thoracic trauma is associated to the patient’s systemic severity. Non-invasive ventilation is a supportive treatment indicated in physiologically stable patients regardless of the severity of thoracic injury.

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A Method to Discriminate Pulmonary Contusion Severity Through Analysis of Hounsfield Unit Frequency

ASME 2007 Summer Bioengineering Conference ◽

10.1115/sbc2007-176906 ◽

2007 ◽

Author(s):

F. Scott Gayzik ◽

Melissa Daly ◽

Joel Stitzel

Keyword(s):

Three Dimensional ◽

Hounsfield Unit ◽

Pulmonary Contusion ◽

Thoracic Injury ◽

Strong Positive Correlation ◽

X Rays ◽

Novel Approach ◽

Chest X Ray ◽

Predicting Outcome

This study presents a novel approach for the quantification and classification of pulmonary contusion (PC). PC is a common thoracic injury, affecting up to 25% of patients sustaining blunt chest trauma. [1] Contusion volume at the time of hospitalization has been shown to be an independent predictor for the development of Acute Respiratory Distress Syndrome (ARDS), with the risk of ARDS increasing sharply with PC in excess of 20% by volume. [1] Despite the frequency of the injury and strong positive correlation between contusion volume and outcome, there are relatively few contusion quantification methods in the current literature. One such study utilized chest x-ray film to score PC according the amount of lung appearing to be damaged. [2] The study concluded that despite the limitations in using chest x-rays, a PC scoring system may be of value in determining the need for ventilator assistance and predicting outcome. A potentially more accurate approach to quantifying the severity of PC is through the use of computed tomography (CT) chest scans. CT is the preferred modality for obtaining volumetric pulmonary contusion data since the complete three-dimensional lung anatomy is captured. In this work a semi-automated approach is used to analyze PC in an isolated model of lung contusion in the rat. [3, 4] The CT-based approach enables the PC to be precisely quantified as the lesion progresses in time. The technique distinguishes the severity of the contusion by analyzing the composition of bands in the Hounsfield Unit (HU) range of lung image masks.

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The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review

The American Surgeon ◽

10.1177/000313481808400329 ◽

2018 ◽

Vol 84 (3) ◽

pp. 428-432 ◽

Cited By ~ 2

Author(s):

Gregory R. Stroh ◽

Fanglong Dong ◽

Elizabeth Ablah ◽

Jeanette G. Ward ◽

James M. Haan

Keyword(s):

Retrospective Review ◽

Trauma Center ◽

Traumatic Injury ◽

Hospital Length Of Stay ◽

Drug Screen ◽

Trauma Patients ◽

Urine Drug Screen ◽

Increased Risk ◽

Level I ◽

The Impact

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

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Rib Fractures and Mortality: Breaking the Causal Relationship

The American Surgeon ◽

10.1177/000313481908501127 ◽

2019 ◽

Vol 85 (11) ◽

pp. 1224-1227 ◽

Cited By ~ 1

Author(s):

Brittany Bankhead-Kendall ◽

Sepeadeh Radpour ◽

Kevin Luftman ◽

Erin Guerra ◽

Sadia Ali ◽

...

Keyword(s):

Blunt Trauma ◽

Injury Severity ◽

Rib Fractures ◽

Rib Fracture ◽

Direct Result ◽

P Value ◽

Trauma Patients ◽

Injury Score ◽

Urban Level ◽

Level I

Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008–2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older ( P < 0.0001) and had a higher admission respiratory rate ( P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3–13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.

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First rib fractures as indicators of serious intra and extra-thoracic injury in polytrauma and their impact on the morbidity and mortality

International Surgery Journal ◽

10.18203/2349-2902.isj20191251 ◽

2019 ◽

Vol 6 (4) ◽

pp. 1056

Author(s):

Majed Al-Mourgi

Keyword(s):

Cervical Spine ◽

Injury Severity ◽

Motor Vehicle ◽

Rib Fractures ◽

Rib Fracture ◽

Morbidity And Mortality ◽

Pulmonary Contusion ◽

Thoracic Injury ◽

Thoracic Injuries ◽

First Rib

Background: First-rib fractures are relatively rare compared with fractures of other ribs because of the broad structure deeply placed and protected location of the first rib. A high amount of energy is needed to cause a first-rib fracture; violent trauma, such as that involving motor vehicle accident, is a frequent cause of these fractures, as well as other serious intra-thoracic, head, cervical spine, and intra-abdominal injuries. First-rib fractures have traditionally been considered indicators of increased injury severity and mortality in major trauma patients. The aim was to study the significance of first-rib fractures as indicators of serious intra-thoracic and extra-thoracic injury in polytrauma and their impact on the morbidity and mortality in a high-altitude area in Al-Taif, Saudi Arabia.Methods: This is a retrospective study conducted in King Abdul-Aziz Specialist Hospital (KASH), Taif City, KSA. Patients with chest injuries who presented to the emergency department and were admitted to the hospital between November 2013 and March 2016 were included in the study. Data regarding first-rib fracture were collected, and the relationship between first-rib injuries and associated intra-thoracic and extra-thoracic injuries was analyzed.Results: There was a high incidence of first-rib fracture (23.45%), and 35.8% were bilateral. The most common associated chest injury was a pulmonary contusion (58.5%), followed by pneumothorax (32.1%), hemopneumothorax (20.7%), and surgical emphysema (20.7%). The most common associated extra-thoracic injuries in our study were skeletal injuries (47.4%), cervical spine injuries (11.3%), and head trauma (24.5%).Conclusions: Fractures of the first-rib are associated with serious thoracic and extra-thoracic injuries; they are associated only with increased morbidity in patients with polytrauma and have no independent impact on mortality.

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The Effect of Prehospital Transport Time on the Mortality from Traumatic Injury

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00041625 ◽

1995 ◽

Vol 10 (1) ◽

pp. 24-29 ◽

Cited By ~ 58

Author(s):

Roland W. Petri ◽

Alan Dyer ◽

John Lumpkin

Keyword(s):

Analysis Of Variance ◽

Trauma Center ◽

Injury Severity ◽

Traumatic Injury ◽

Trauma Patients ◽

Transport Time ◽

Patient Transport ◽

Severity Of Injury ◽

Level I ◽

Prehospital Time

AbstractObjective:To test the hypothesis that a prehospital time threshold (PhTT) exists that when exceeded, significantly increases the mortality of trauma patients transported directly from the scene of injury to a trauma center rather than to the closest hospital.Design:Review of data contained within the Illinois Trauma Registry encompassing the period from fall 1989 through spring 1991.Participants:A total of 5,215 injured persons with an Injury Severity Score (ISS) >10, cared for in an Illinois level-I or -II trauma center outside of the city of Chicago.Measurements:Injury severity expressed as ISS, scene time (ST), transport time (TrT), total emergency medical services time (TEMST), and outcome were determined for each patient. Patients were stratified into groups on the basis of ISS.Results:Patient outcomes were significantly different statistically between ISS groups (p <0.001, X2). Mean ST and TEMST, but not TrT, were significantly different statistically between ISS groups (p <0.001, analysis of variance). Lower ISS was associated with longer times. Mean ST, TrT, and TEMST were significantly different statistically between survivors and nonsurvivors (p <0.001, two-sample t-tests). Survival was associated with longer times. Each of the mean times remained significantly different between survivors and nonsurvivors after controlling for severity of injury (p <0.001, two-way analysis of variance).Conclusion:No PhTT beyond which time patient transport to the closest hospital would have decreased mortality was identifiable, because no prehospital time <90 minutes exerted a significant adverse effect upon survival.

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