Ten-year reduction in thoracic injury-related mortality among Israel Defense Forces soldiers

IntroductionThis study aims to describe injury patterns, prehospital interventions and mortality rates of combat-related thoracic injuries during the past decade among Israel Defense Forces (IDF) soldiers before and after implementation of the 2012 IDF-Military Corps ‘My Brother’s Keeper’ plan which included the publication of clinical practice guidelines (CPGs) for thoracic injuries, emphasis on adequate torso protection, introduction of modern life-saving procedures and encouragement of rapid evacuation.MethodsThe IDF prehospital trauma registry was reviewed to identify all patients who sustained thoracic injuries from January 2006 to December 2017. IDF soldiers who were injured, died of wounds or killed in action (KIA) were included. These were cross-referenced with the Israel National Trauma Registry. The periods before and after the plan were compared.Results458 (12.3%) of 3733 IDF soldiers wounded on the battlefield sustained combat-related thoracic injuries. The overall mortality was 44.3% before the CPG and 17.3% after (p<0.001). Most were KIA: 97% (95 of 98) died by 30 June 2012, and 83% (20 of 24) after (p<0.001). Casualties treated with needle thoracostomy before and after CPG were 6.3% and 18.3%, respectively (p=0.002). More tube thoracostomies were performed after June 2012 (16.1% vs 5.4%, p=0.001). Evacuation was faster after June 2012 (119.4 min vs 560.8 min, p<0.001), but the rates of casualties evacuated within 60 min were similar (21.1% vs 25%, p=0.617).ConclusionsAmong military casualties with thoracic injuries, the rate of life-saving interventions increased, evacuation time decreased and mortality dropped following the implementation of My Brother’s Keeper plan.

Physician-Led Thoracic Trauma Management in a Specialist Emergency Care Centre

Introduction: Falls cause 75% of trauma in patients above 65 years of age, and thoracic trauma is the second commonest injury; rib fractures are the most common thoracic injury. These patients have up to 12% mortality, with 31% developing pneumonias. There is wide variation in care. Northumbria Healthcare has a team of respiratory consultants, physiotherapists, specialist nurses and anesthetists for thoracic-trauma management on a respiratory support unit. Methods: With Caldicott approval, basic demographics and clinical outcomes of patients admitted with thoracic trauma between 20 August 20–21 Aprilwere analyzed. A descriptive statistical methodology was applied. Results: A total of 119 patients were identified with a mean age of 71.1 years (range 23–97). Of the 119 patients, 53 were male, 66 females. The main mechanism of injury was falls from standing (65) and falls down stairs/bed or in the bath (18). Length of stay was 7.3 days (range 1–54). In total, 85 patients had more than one co-morbidity, 26 had a full trauma assessment and 75 had pan CTs. The mean number of rib fractures was 3.6 and 31 (26%) patients had a pneumothorax and/or haemothorax. A total of 18 chest drains were inserted (all small bore) and one needle aspiration was performed. No cardiothoracic input was required. Isolated chest trauma was present only in 45 patients. All patients had a pain team review, 22 erector spinae catheters were inserted with 2 paravertebral blocks. Overall, 82 patients did not require oxygen, 1 required CPAP and 1 HFNC. 7 needed intensive care transfer. Furthermore, 20 (17%) developed pneumonias and 16 (14%) deaths occurred within 30 days—all were in those with falls from standing. There was no correlation between number of fractured ribs, length of stay and mortality. Conclusions: High level care for thoracic trauma can be performed by a physician led team. Overall, 42% pneumothoraces/haemothoraces were observed. Further large scale randomised trials are warranted for definitive outcomes.

A Case Report of Delayed Hemothorax Complicated by Fibrothorax

Delayed hemothorax is a potentially life-threatening complication of thoracic trauma that should be carefully considered in all patients presenting with thoracic injury. We report a case of delayed hemothorax in a 77-year-old male presenting eleven days’ status post multiple right mid- to high-rib fractures. His case was complicated by retained hemothorax after CT-guided chest-tube with subsequent video-assisted tube thoracostomy (VATS) revealing fibrothorax necessitating conversion to open thoracotomy. Known risk factors for development of delayed hemothorax include older patient age, three or more rib fractures, and presence of mid- to high-rib fractures, and should be used in risk stratification of thoracic trauma. Tube thoracostomy is often sufficient in management of delayed hemothorax. In rare cases, hemothoraces can be complicated by retained hemothorax or fibrothorax, which require more invasive therapy and carry greater morbidity and mortality.

The major trauma patient

This chapter describes the anaesthetic management of the major trauma patient. It begins with immediate trauma care, the patient journey, primary survey and resuscitation. The management of head and traumatic brain injury, thoracic injury, abdominal and pelvic injuries, spinal injury, limb and extremity injury, blast injury and gunshot wounds and traumatic cardiac arrest are discussed. The specific management of burns, paediatric trauma and silver trauma are covered. Anaesthesia for major trauma, including damage control resuscitation and damage control surgery are discussed.

Predictive Factors of Ventilatory Support in Chest Trauma

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.

Epidemiology and Impact of Thoracic Trauma on the Mortality of Multi-trauma Patients: Results From a French Road Trauma Registry 1997-2016

Thoracic trauma is the third most common cause of death in multi-trauma patients. One of the most frequent mechanism is road traffic accident (RTA). The objective of the present study was to investigate the influence of severe (abbreviated injury scale, AIS≥3) injuries in each body region on the mortality of multi-trauma patients with a particular attention to thoracic trauma. We also described the epidemiology and injury pattern of these patients when presenting with at least one AIS ≥2 thoracic injury (AISThorax≥2). Patients included in the Rhône RTA registry between 1997 and 2016, with at least one AIS ≥2 injury in any body region were included. Two subgroups were defined according to whether patients presented at least one AISThorax≥2 injury or not. Multivariate regression analysis with mortality as outcome was performed. A total of 46,526 patients had at least one AIS≥2 injury, among them 6,382 (13.7%) had at least one AISThorax≥2 injury. Severe thoracic injuries (OR=12.2, 95%CI [8.4;17.7]) were strongly associated with death, second to severe head injuries were (OR=26.8, 95%CI [20.4;35.2]). Chest wall injuries were the most frequent thoracic injury (62.1%, n=5,419) and 52.4% of these were multiple rib fractures. Severe thoracic injury is a priority in multi-trauma patients; both in the detection but also in the management.

Impact of Thoracic Trauma on the Mortality of Multi-trauma Patients: It Matters - Results From a French Road Trauma Registry 1997-2016

BackgroundThoracic trauma is the third most common cause of death in multi-trauma patients and is associated with poor short-term outcomes since it is responsible for up to 25% of trauma-related deaths. One of the most frequent mechanism is road traffic accident (RTA), affecting particularly young patients. The primary objective of the present study was to investigate the influence of severe injuries in each body region on the mortality of multi-trauma patients with a particular attention to thoracic trauma. Secondary objectives were to investigate risk factors for mortality in multi-trauma patients but also to describe the epidemiology and injury pattern of these patients when presenting with at least one abbreviated injury scale (AIS) ≥2 thoracic injury (AISThorax≥2).MethodsRetrospective study that included RTA occurring from January 1997 to December 2016. Patients of all ages included in the Rhône RTA registry, with at least one AIS ≥2 injury in any body region were included. Two subgroups were defined according to whether patients presented at least one AISThorax≥2 injury or not. Multivariate regression analysis with mortality as outcome was performed. ResultsA total of 46,526 patients had at least one AIS≥2 injury, among them 6,382 (13.7%) had at least one AISThorax≥2 injury. In the AISThorax≥2 group, the median [IQR] ISS was 14 [6-7] and 16.2% (n=1,031) patients died. Severe (AIS≥3) head (OR=26.8, 95%CI [20.4;35.2]) and thoracic (OR=12.2, 95%CI [8.4;17.7]) injuries were associated with death; as was age [40-59 years (OR=1.3, 95%CI [1.1;1.5]), 60-79 years (OR=2.1, 95%CI [1.7;2.6]), and ≥80 years (OR=5.5, 95%CI [4.2;7.3])], male sex (OR=1.5, 95%CI [1.3;1.7]), RTA occurring in a highway (OR=1.9, 95%CI [1.5;2.4]) or in a rural road (OR=1.8, 95%CI [1.5;2.1]). The most frequent thoracic injury was that of the chest wall (62.1%, n=5,419). The most frequent concomitant AIS≥2 injuries affected the head (29.1%), upper extremities (26.8%), and lower extremities (25.8%).ConclusionsThe present study found that the severity of thoracic trauma was an independent and significant risk factor for death in multi-trauma patients as was age, being a car occupant and having a crash in a rural road or a highway.