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Purpose: This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. Design: Systematic review and meta-analysis. Data sources: Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. Review methods: The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. Results: Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49–71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48–62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17–1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. Conclusion: Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. Level of evidence: Level III, systematic review and meta-analysis. [ABSTRACT FROM AUTHOR]

Abstract Background Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. Methods A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. Results From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I 2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P

Background: Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. Methods: A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. Results: From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. Conclusion: Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. Systematic review registration: UMIN Clinical Trials Registry UMIN000049365. [ABSTRACT FROM AUTHOR]

Background: After cardiovascular and cancer, the third leading cause of death is trauma. Death due to trauma usually occurs in the first four decades of life. Thoracic injuries are a severe problem due to high-speed vehicle accidents. The two significant types of trauma are penetrating trauma and blunt trauma. Penetrating injuries usually result in the disruption of tissue structure, while blunt injuries result in organ damage or any structure under the tissue without damaging the integrity of that tissue. Blunt injuries include falling from a height, a traffic accident, or job-related injuries. Method: This is a cross-sectional study conducted for one year, and a sample size of 293 was taken. The study encompassed the bodies of patients eligible for autopsy, excluding those with mutilated or decomposed bodies, as well as those with insufficient historical information. Autopsies were conducted following proper patient identification and examination. A T-test was employed to compare male and female groups, while the chi-squared test assessed differences in categorical variables between groups. Data analysis was performed using SPSS version 24.0. A value of P < 0.05 was considered significant. Result: The study revealed that most of the chest trauma cases occurred in males 70.3% and females 29.7%. Maximum number of trauma was seen between the age group of 21 to 30 years. Out of 293 victims, 235 have blunt injuries, and 58 have penetrating injuries, lung contusion is the most common 51.8% followed by rib fracture, which has occurred in 46.4% victims. Conclusion: The rate of occurrence of chest trauma is higher in males between the age group of 21 to 30 years than females of the same age group. Similarly, the prevalence of blunt chest trauma is much higher as compared to penetrating chest trauma. In blunt injury, the incidence of traffic-related injuries is higher, while in penetrating injuries, stabbing is more common than any other injuries. [ABSTRACT FROM AUTHOR]

Thoracic injury crucially threatens human health. Recent studies have suggested using computed tomography (CT) to observe traumatic pneumothorax (PTX). However, cross-ethnic validation is required to overcome potential barriers for the global application of this method. This study aimed to validate the 35-mm rule in traumatic PTX in a Korean population. Data from the institutional registry were analyzed, and chest CT images were reviewed. Factors for observation failure were evaluated via logistic regression analysis, and a receiver-operating curve was created to calculate the optimal cutoff value. In total, 286 participants were included in this study. The average PTX size was 8.2 (3.2–26.5) mm, and 210 of 213 (95.3%) initially observed patients with a PTX size of ≤35 mm successfully completed the safety observation. Multivariate regression analysis revealed that a PTX size of >35 mm is associated with observation failure and suggested a cutoff of 24.5 mm. Most patients with traumatic PTX of ≤35 mm on CT had undergone successful 4-h observation without thoracostomy. Additionally, PTX of >35 mm was an independent risk factor for observation failure. Considering the lower optimal cutoff value and high failure rates observed in this study, the current guidelines need modifications. [ABSTRACT FROM AUTHOR]

Background: Muscle-sparing thoracotomy (MST) has been proposed as an alternative to standard posterolateral thoracotomy (sPLT) for elective thoracic procedures with limited use in urgent thoracotomies.Objectives: The aim of this study was to compare the results of sPLT and MST during urgent thoracotomy for the treatment of chest trauma.Methods: This case series study included patients who underwent urgent thoracotomies within the first 48 hours of admission for treatment of chest trauma, from January 2019 to July 2022. Patients were divided into two groups: sPLT and MST groups. In addition, the MST group was divided into partial (pMST) or complete (cMST).‎Results: Seventy-five out of 1400 patients with chest trauma (5.3%) underwent urgent thoracotomy, and 30 of them (40%) had MST. Compared with the sPLT group, the MST group had a lower abbreviated injury scale (AIS) of the thoracic region, with a significant difference (4.09 ± 0.66 versus 3.77 ± 0.72, P = 0.052). There was no significant difference between the two groups with regard to the duration of tube drainage, ICU stay, hospital stay, and postoperative complications. The length of hospital stay was shorter in the MST group with no statistically significant difference (14.30 ± 3.01 vs. 15.5 ± 2.48, P = 0.08). The extent of MST, whether partial or complete, had no significant effect on postoperative outcomes.Conclusions: If it does not impede access or chest exposure, MST can be performed with early recovery and therefore a shorter hospital stay than sPLT.

Michael Jiang,1 Varun Peri,1 Bobby Ou Yang,1 Jaewon Chang,2 Douglas Hacking1 1Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia; 2Department of Surgery, St George Hospital, Sydney, New South Wales, AustraliaCorrespondence: Michael Jiang, Department of Anaesthesia, Austin Health, 145 Studley Road, Heidelberg, 3084, Victoria, Australia, Email Michael.jiang49@gmail.comIntroduction: Rib fractures are a common sequelae of chest trauma and are associated with significant morbidity. The erector spinae nerve block (ESB) has been proposed as an alternative first-line regional technique for rib fractures due to ease of administration and minimal complication profile. We aimed to investigate the current literature surrounding this topic with a focus on pain and respiratory outcomes.Methods: A comprehensive literature search was performed on the Medline, Embase, Web of Science, Scopus, and Cochrane databases. Keywords of “erector spinae block” and “rib fractures” were used to form the search strategy. Papers published in English investigating ESB as an analgesic intervention for acute rib fracture were included. Exclusion criteria were operative rib fixation, or where the indication for ESB was not rib fracture.Results: There were 37 studies which met the inclusion criteria for this scoping review. Of these, 31 studies reported on pain outcomes and demonstrated a 40% decrease in pain scores post administration within the first 24 hours. Respiratory parameters were reported in 8 studies where an increase in incentive spirometry was demonstrated. Respiratory complication was not consistently reported. ESB was associated with minimal complications; only 5 cases of haematoma and infection were (incidence 0.6%) reported, none of which required further intervention.Discussion: Current literature surrounding ESB in rib fracture management provides a positive qualitative evaluation of efficacy and safety. Improvements in pain and respiratory parameters were almost universal. The notable outcome from this review was the improved safety profile of ESB. The ESB was not associated with complications requiring intervention even in the setting of anticoagulation and coagulopathy. There still remains a paucity of large cohort, prospective data. Moreover, no current studies reflect an improvement in respiratory complication rates compared to current techniques. Taken together, these areas should be the focus of any future research.Keywords: chest trauma, thoracic injury, regional anaesthesia, nerve block

Background: Occult pneumothorax (OPTX) is found in up to 15% of chest injuries. There is a history of conservative management of this pathology (only observation), although its practice continues to be discussed, especially in penetrating trauma. The objective of this paper is to describe our experience in the conservative management of OPTX. Materials and Method: Retrospective cohort study conducted over a 3-year period at a level I Trauma Center. Patients with thoracic trauma (blunt or penetrating) with OPTX were included. They were divided into two groups (preserved or drained) comparing their evolution. Results: Over a 3-year period 679 patients were admitted with chest trauma. From 93 patients with OPTX, 74 (80%) were initially preserved and 19 (20%) drained. Two patients (3%) presented pneumothorax progression in the follow-up imaging. There were no complications related to the absence of pleural drainage. Complications and hospital stay were lower in the conservative management group. Conclusion: Patients with OPTX due to chest trauma (blunt or penetrating), without requiring assisted ventilation and hemodynamically stable, can be safely conservative managed with close monitoring for 24 hours, with a lower rate of complications and hospital stay. [ABSTRACT FROM AUTHOR]

Introduction: Sternal fractures (SF) are uncommon injuries usually associated with a significant mechanism of injury. Concomitant injury is likely, and a risk of mortality is substantial. Aim: Our aim in this study was to identify the risk factors for mortality in patients who had sustained sternal fractures. Methods: We conducted a single centre retrospective review of the trust's Trauma Audit and Research Network Database, from May 2014 to July 2021. Our inclusion criteria were any patients who had sustained a sternal fracture. The regions of injury were defined using the Abbreviated Injury Score. Pearson Chi-Squared, Fisher Exact tests and multivariate regression analyses were performed using IBM SPSS. Results: A total of 249 patients were identified to have sustained a SF. There were 19 patients (7.63%) who had died. The most common concomitant injuries with SF were Rib fractures (56%), Lung Contusions (31.15%) and Haemothorax (21.88%). There was a significant increase in age (59.93 vs 70.06, p =.037) and admission troponin (36.34 vs. 100.50, p =.003) in those who died. There was a significantly lower GCS in those who died (10.05 vs. 14.01, p <.001). On multi regression analysis, bilateral rib injury (p = 0.037, OR 1.104) was the only nominal variable which showed significance in mortality. Conclusion: Sternal Fractures are uncommon but serious injuries. Our review has identified that bilateral rib injuries, increase in age, low GCS, and high admission troponin in the context of SF, were associated with mortality. [ABSTRACT FROM AUTHOR]

Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway "bundles of care" are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a "bundle of care" in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case–control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient's individual circumstances, clinical background, and prognostic projections. [ABSTRACT FROM AUTHOR]

In 2020, 17% of all crash fatalities were individuals aged 65 years or older. Crash data also revealed that for older occupants, thoracic related injuries are among the leading causes of fatality. Historically, the majority of near-side impact postmortem human subjects (PMHS) studies used a generic load wall to capture external loads that were applied to PMHS. While these data were helpful in documenting biofidelity, they did not represent a realistic response an occupant would undergo in a near-side crash. The objective of this research was to test small, elderly female PMHS in a repeatable, realistic near-side impact crash scenario to investigate current injury criteria as they relate to this vulnerable population. Ten small, elderly PMHS were subjected to a realistic near-side impact loading condition. The PMHS were targeted to be elderly females age 60+, approximately 5th percentile in height and weight, with osteopenic areal bone mineral density. Each subject was seated on a mass-production seat, equipped with a side airbag and standard three-point restraint with a pretensioner. Other boundary conditions included an intruding driver's side door. PMHS instrumentation included strain gages on ribs 3-10 bilaterally to identify fracture timing. Two chestbands were used to measure chest deflection, one at the level of the axilla and one at the level of the xiphoid process. Injuries observed included rib fractures, particularly on the struck side, and in multiple cases a flail chest was observed. Eight of ten subjects resulted in AIS3+ thoracic injuries, despite previously tested ATDs predicting less than a 10% chance of AIS3+ injury. Subjects crossed the threshold for AIS3 injury in the range of only 1% − 9% chest compression. Additionally, mechanisms of injury varied, as some injuries were incurred by door interactions while others came during airbag interactions. This research points to two areas of concern that likely require further analysis: (1) the appropriateness of potentially oversimplified PMHS testing to establish injury thresholds and define injury criteria for complicated crash scenarios; (2) the importance of identifying the precise timing of injuries to better understand the effect of current passive restraint systems. [ABSTRACT FROM AUTHOR]

Background: Muscle-sparing thoracotomy (MST) has been proposed as an alternative to standard posterolateral thoracotomy (sPLT) for elective thoracic procedures with limited use in urgent thoracotomies. Objectives: The aim of this study was to compare the results of sPLT and MST during urgent thoracotomy for the treatment of chest trauma. Methods: This case series study included patients who underwent urgent thoracotomies within the first 48 hours of admission for treatment of chest trauma, from January 2019 to July 2022. Patients were divided into two groups: sPLT and MST groups. In addition, the MST group was divided into partial (pMST) or complete (cMST). Results: Seventy-five out of 1400 patients with chest trauma (5.3%) underwent urgent thoracotomy, and 30 of them (40%) had MST. Compared with the sPLT group, the MST group had a lower abbreviated injury scale (AIS) of the thoracic region, with a significant difference (4.09 ± 0.66 versus 3.77 ± 0.72, P = 0.052). There was no significant difference between the two groups with regard to the duration of tube drainage, ICU stay, hospital stay, and postoperative complications. The length of hospital stay was shorter in the MST group with no statistically significant difference (14.30 ± 3.01 vs. 15.5 ± 2.48, P = 0.08). The extent of MST, whether partial or complete, had no significant effect on postoperative outcomes. Conclusions: If it does not impede access or chest exposure, MST can be performed with early recovery and therefore a shorter hospital stay than sPLT. [ABSTRACT FROM AUTHOR]

• Previous literature shows superior outcomes for traumatically injured patients treated at Level I trauma centers. We sought to determine if this applies to pediatric patients with penetrating thoracic injuries. • Retrospective review (2013–2016) demonstrated outcomes improved when patients were treated at adult Level I centers and with increased annual case volume. • Firearms were responsible for the majority of penetrating injuries in these pediatric patients and accounted for the highest injury burden and majority of deaths. We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI). PTI patients <18 years were identified from the National Trauma Data Bank (2013–2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance. We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers. Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes. Level III. [ABSTRACT FROM AUTHOR]

We describe the case of an elderly male patient who presented with a proximal descending aortic aneurysm after a motorcycle accident in 1977. We concluded that the aorta had been transected at that time. In a rather unconventional manner, the aneurysm developed a circumferential layer of calcification that provided mechanical stability and likely prevented further degeneration. We chose not to pursue surgical intervention at the late stage of his presentation. The patient has been followed up for a period of 30 years, with no change in the size and shape of the now completely calcified aneurysm.

This study aims to identify independent factors associated with cervical spinal injuries in head-injured patients. The extent of injuries to other body parts was assessed by the Abbreviated Injury Scale (AIS) and was included in the analysis. Consecutive head-injured patients admitted via the emergency department from January 1, 2014 to December 31, 2016 were retrospectively reviewed. The inclusion criteria were head-injured patients with an Abbreviated Injury Scale (AIS) score ≥2 (i.e., head injuries with intracranial hematoma or skull fracture). Patients with minor head injuries with only scalp abrasions or superficial lacerations without significant intracranial injuries (i.e., head injury AIS score = 1) were excluded. The primary outcome was to identify independent predictors associated with cervical spinal injuries in these head-injured patients. Univariate and multivariable analyses were conducted. A total of 1105 patients were identified. Of these patients, 11.2% (n = 124) had cervical spinal injuries. Univariate and multivariable analyses identified male gender (P = 0.006), the presence of thoracic injury (including rib fracture, hemothorax, or pneumothorax) (P = 0.010), and hypotension with systolic blood pressure <90 mm Hg on admission (P = 0.009) as independent predictors for cervical spinal injury in head-injured patients. This study showed that about 1 in 10 patients with significant head injury had cervical spine injury, usually associated with fracture or dislocation. Male gender, the presence of thoracic injury, and hypotension on admission were independent risk factors associated with cervical spinal injuries. [ABSTRACT FROM AUTHOR]

The objective of this study is to generate age targeted versions of the male and female Global Human Body Models Consortium (GHBMC) occupant human body models (HBMs), to validate each in frontal impacts, and to assess rib fracture probability of each. Six age targeted models were developed based on the GHBMC average male and small female occupant models (M50-O v6.0 and F05-O v6.0, respectively). All age targeted models were modified to represent population means for height, weight, shape, and relevant material properties. The thin plate spline method was used to morph models, and material properties were modified using available literature. Validation focused on chest response. Models were evaluated in a rigid body frontal chest impact at 6.7 m/s. Furthermore, the male and female age targeted models were evaluated against published data from 40 km/hr and 30 km/hr frontal sled tests respectively. Chest deflections and landmark kinematics reasonably matched the respective corridors in the M50-O and F05-O aged models. Regional probability of rib fracture was assessed using probabilistic methods based on cortex strain. Increasing rib fracture with age was observed in both impacts for both sexes. For the rigid chest impact, the M50-O 70YO resulted in 10 ribs exceeding 50% probability of fracture whereas the younger ages reported 4 to 6 ribs exceeding the same probability. In the same simulation, the F05-O 70YO resulted in 8 regions exceeding 50% probability of rib fracture as opposed to 3 and 0 such regions at the youngest ages. Sled simulation demonstrated similar trends. The 70YO age adjusted models best aligned with the reported extent of fractures from the referenced PMHS studies, which tend to be composed of subjects of advanced age. Age targeted HBMs demonstrated increased fracture probability with age when subjected to equivalent impacts. Gross model kinematics approximate PMHS data but showed little difference between targeted age models. The findings indicate that while gross kinematics are unaffected by age-targeting models, such models can capture trends of increased thoracic injury risk observed in experimental and field studies, and further suggest their potential use to target interventions for vulnerable driving populations, such as older adults. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods: This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results: Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p

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Purpose: The purpose of the study is to analyze the diagnosis and treatment of patients with traumatic chest injuries and traumatic hemopneumothorax in UMHATEM "N. I. Pirogov ". Material and Methods: Data on 113 patients with thoracic trauma were processed within a retrospective clinical analysis for the period of 1.1. 2016 to 1.1. 2018 in the General, Visceral and Emergency Surgery Section of the UMHATEM "Pirogov. Of the hospitalized women are 38 (33.63%), men 75 (66.37%). The age in this retrospective analysis varied from 18 to 83 years (average 57.4 years). Results: In our study, among 113 patients, 43 patients had a pneumothorax, 29 patients were with hemothorax, 18 patients with hemopneumothorax, 2 patients had tension pneumothorax and others 21 had only rib fractures. Associated injuries were confirmed in 43 patients (38.05%). From all patients group, 21 patients were managed conservatively, 89 patients with chest tube insertion and only 3 with thoracotomy. Conclusions: The majority of the patients with a thoracic injury can be performed in emergency surgery by conservative management or by mini-intervention- thoracic chest tube. Tube thoracostomy was evaluated to be important for pleural collections from blunt or penetrating trauma. Therefore it was recommended as a first-line therapeutic approach.

Purpose: Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center. Methods: Data of 168 patients' ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed. Results: Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods. Conclusions: Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma. [ABSTRACT FROM AUTHOR]

Abstract Background Penetrating thoracic injuries are uncommon in childhood. Massive penetrating injury due to impalement is even more rare and has scarcely been reported. It has a dramatic clinical presentation and is often fatal, depending on the organs injured. Case presentation Two boys presented with an unusual mechanism of injury. They fell from a height to be impaled by a large stick. Appropriate emergency medical service was not available and surgery was delayed by more than 24 h after the accident. Both children were labelled “lucky” as they survived the injury without any significant sequelae. Conclusion We discuss two new cases of pediatric thoracic impalement and perform the first literature review on the subject. Emphasis should be given to the initial care which comprises avoiding premature removal, rapid transport, resuscitation, anti-tetanus and antibiotics. All reported cases had a favorable outcome, even those managed within the constraints of low-income countries.

Abstract Background Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. Methods We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3–5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2–5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value

Background: While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma., Methods: The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location., Results: Propensity score matching yielded 17 716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups ( P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178)., Discussion: CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim of this study is to define the cost of rib fracture hospitalization by single, multiple, and flail type using a nationally representative sample.Methods: The national inpatient sample (NIS) was used to identify patients with a primary diagnosis of rib fracture hospitalization 2007-2016. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to characterize patients as having single, multiple, or flail chest rib fractures. Patients with only trauma related diagnosis groups (DRG) at the time discharge were included in the final sample. The cost of hospitalization was obtained by converting reported charges into cost using the all-payer inpatient cost-to-charge ratio (CCR) for all hospitals in the NIS data. The log of cost was modeled using multivariate linear regression. The rib fracture type was the primary predictor in the model.Results: There were 373,053 rib fracture admissions during 2007-2016. The average cost per hospitalization was $10,169 (95%Confidence Interval [CI]: 9,942-10,395), which translated into a national expenditure of $3.64 billion over 10 years. The cost of rib fracture hospitalization increased from $209 million in 2007 to $469 million in 2016. Compared to single rib fracture patients, the cost of hospitalization for multiple rib fractures and flail chest was 3% (p = 0.001) and 5% (p=0.02) higher, respectively. Higher injury severity score, total number of body regions injured and longer length of stay were associated with higher rib fracture hospitalization cost.Conclusions: Rib fractures affect ~22,000-45,000 people per year in the United States. The cost of rib fractures is over $469 million per year and is increasing over time. Multiple rib fractures and flail chest rib fractures are associated with increased cost. Pathways to improve care in patients with rib fractures should consider the cost of treatment. [ABSTRACT FROM AUTHOR]

Background and objective: With respect to the resource and training requirements of a Swiss trauma center, we wanted to know how frequently relevant thoracic injuries occur and how often specialized thoracic surgery is needed. Material and methods: Retrospective analysis of all severely injured patients with a new injury severity score (NISS) ≥8 from 2010–2017 with respect to relevant thoracic injuries (abbreviated injury scale, AIS thorax without thoracic vertebral injuries ≥2). Results: In the 7‑year observational period 2839 patients with NISS ≥8 were treated as an emergency. Of these 791 (27.9%) suffered a relevant injury in the thoracic region and 27.1% (n = 215) of them required a thoracic intervention, which in 86.5% (n = 186) corresponded to a thoracic drainage only and in 13.5% (n = 29) to an extended intervention. In 19 cases following relevant thoracic injury, a thoracic surgeon was also required, 4 times immediately and 4 times within 24 h of hospital arrival. On average, 30 emergency thoracic drainage insertions per year corresponded to 1–2 interventions per surgeon in training. Conclusion: In the observational period only 1% of all relevant thoracic injuries required emergency thoracic surgical care beyond a pleural drainage. Given this low rate, for efficiency and cost reasons a thoracic surgery on-call service appears to be appropriate and compulsory attendance is not needed; however, the capability to insert a thoracic drainage must be appropriately assured by surgical training. In view of the number of cases observed per trainee, the minimum number of interventions required according to specialty training regulations should be well achievable. [ABSTRACT FROM AUTHOR]

Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay. [ABSTRACT FROM AUTHOR]

Objectives: Modern vehicles generally use steel fabricated or alloy blended rims. The manufacturing process and atomic structure of the rim both yield different responses under destructive loading. The aim of this research was to investigate to what extend the type of vehicle rim may influence occupant injury risk.Methods: A matched cohort study of frontal German In-Depth Accident Study collisions was devised. The risk of injury to various body regions was compared between vehicles with steel and alloy rims.Results: Occupants in vehicles with alloy rims were at a greater risk of thoracic injury (relative risk [RR] = 1.57; 95% confidence interval [CI], 1.01-2.42) and thoracic abdomen injury (RR = 1.62; 95% CI, 1.10-2.39) at the Maximum Abbreviations Injury Scale (MAIS) 2+ severity. Risk of thoracic injury was greatest for the cluster of occupants seated on the nonimpacted side in frontal collisions (RR = 2.21; 95% CI, 1.01-4.86). MAIS 2+ injury to the head/face/neck yielded no association (RR = 0.98; 95% CI, 0.66-1.47).Conclusion: Alloy rims are more brittle and, as a result, destructive loading is realized with less severe impact. The critical failure increases the amount of loading that needs to be distributed by the restraint system and results in injury. [ABSTRACT FROM AUTHOR]

The most common thoracic injury in children, resulting in trauma, is pulmonary contusion (PC). Bone marrow–derived mesenchymal stem cells (BM-MSCs) are used in wound healing and many other diseases. This study aims to examine the effects of BM-MSCs on PC healing in rats. A total of 45 male Wistar albino rats were used. Four groups were formed. BM-MSCs were labeled with the green fluorescent protein. PC was observed in the control group. In group II, PC occurred and left to spontaneous healing. In group III, PC formed and BM-MSCs were given. In group IV, BM-MSCs were given without PC formation. Subjects were sacrificed 1 week later. Whether there was any difference in terms of BM-MSC involvement and lung injury score was investigated. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 17.0, software (SPSS Inc., Chicago, IL), and p value of <0.05 was considered statistically significant. BM-MSCs were collected much more in the lungs in group III than in group IV. Group III had a lower lung injury score value than group II. The greater involvement of the BM-MSCs in the injury site, and further reductions in lung injury score suggest that BM-MSCs are contributing to the healing of the injury. The use of BM-MSCs in risky patients with diffuse PC may be an alternative treatment to conventional methods. [ABSTRACT FROM AUTHOR]

Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P <.001) and receive intraoperative heparin (94% vs 82%; P =.002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P =.90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P >.9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P =.044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P =.042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P <.001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P =.031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making. [ABSTRACT FROM AUTHOR]

Abstract Background According to recently published findings, we hypothesized that serum interleukin-33 (IL-33) may qualify for predicting pulmonary complications in polytraumatized patients. Methods One hundred and thirty patients (age ≥ 18 years, ISS ≥ 16) were included in our prospective analysis after primary admission to our level I trauma center during the first post-traumatic hour. Serum samples immediately after admission and on day 2 after trauma were obtained and analyzed. Results Median initial IL-33 levels (in picograms per milliliter) were higher in polytrauma victims (1) with concomitant thoracic trauma [5.08 vs. 3.52; p = 0.036], (2) sustaining parenchymal lung injury (PLI) [5.37 vs. 3.71; p = 0.027], and (3) developing acute respiratory distress syndrome (ARDS) [6.19 vs. 4.48; p = 0.003], compared to the respective rest of the study group. The median initial IL-33 levels were higher in patients experiencing both PLI and ARDS compared to those sustaining PLI and not developing ARDS [6.99 vs. 4.69; p = 0.029]. ROC statistics provided an AUC of 0.666 (p = 0.003) and a cut-off value of 4.77 (sensitivity, 71.8%; specificity, 75.7%) for predicting ARDS. Moreover, a higher initial median IL-33 level was revealed in the deceased compared to the survivors [12.25 vs. 4.72; p = 0.021]. ROC statistics identified the initial level of IL-33 as a predictor of death with 11.19 as cut-off value (sensitivity, 80.0%; specificity, 80.0%; AUC = 0.805; p = 0.021). Conclusions Following tissue damage, IL-33 is abundantly released in the serum of polytraumatized patients immediately after their injuries occurred. As initial IL-33 levels were particularly high in individuals experiencing both PLI and ARDS, IL-33 release after trauma seems to be involved in the promotion of ARDS and might serve already at admission as a solid indicator of impending death in polytraumatized patients.

Thoracic injuries account for 20–25% of trauma-related deaths. In cases of pneumothorax the insertion of a chest tube is mandatory but associated with high complication rates particularly when inserted under difficult conditions. The C-Lant is a novel chest-tube insertion device that provides integrated double fixation capabilities and can be used by responders with minimal experience. The aim of the study was to test the device in a large animal model. Pneumothorax, tension pneumothorax, and hemothorax were induced in four white domestic female pigs. The C-Lant device (Vigor Medical Technologies, Haifa, Israel) was inserted as any chest-drain to decompress the thorax. Pull test was applied to test the strength of device fixation. The insertion of the device was simple and effective without detectable negative physiological effects. Reliable fixation was achieved without difficulty. Air and liquid were promptly drained from the chest cavity. Minimal tissue laceration occurred when applying the device in a scenario of erroneous pneumothorax diagnosis with fully expanded lungs. Interconnection with other surgical accessories was smooth. The C-Lant is a novel device that facilitates easy insertion and fixation of chest-tubes by minimally experienced medical providers and reduces the likelihood of unwanted expulsion. Clinical studies are planned. [ABSTRACT FROM AUTHOR]

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: chest trauma is a common cause of mortality, major disability, and the leading cause of death from physical trauma after head and spinal cord injury. Aim: This study aimed to evaluate the effect of educational guidelines on nurses' competence level in caring patients with accidental chest trauma during emergency period. Study design: A one group quasi-experimental research design, with pre and post-test was utilized in this study. Setting: The study was conducted in the emergency department (ER) affiliated to Tanta University Emergency Hospital. Subjects: A convenience sample of all available nurses (60) who are working in ER department, and caring patients with accidental chest trauma affiliated to Tanta University Emergency Hospital, from both sex, different age and agree to participate in the study. Data collection tools: The study data were collected using the following two tools: Tool (1): Nurses' self-administered questionnaire and Tool (2): Nurses' Observational checklist. Results: The present study revealed that there was a highly statistically significant difference between level of nurses' knowledge, practice and attitude pre, post implementation of the educational guidelines. There were significant correlation between nurses educational level and their level of practice and knowledge post implementation of the educational guidelines with (P value= 0.001 & 0.004) respectively as P ≤ 0.05. while there were no significant correlation between nurses' attitude (pre & post) and their level of education as P > 0.05. Conclusion: The implementation of the educational guidelines has a positive effect on nurses' competence level in caring of patients with accidental chest trauma during emergency period throughout the program phases. These findings support the research hypothesis. Recommendations: Regular continuous nursing educational program at least every six months should be implemented for enhancing and updating nurses' knowledge and practice about nursing care offered to patients with accidental chest trauma during emergency period, in order to achieve high quality of care. Nursing care protocol for patients with accidental chest trauma during emergency period should be available in the ER department. [ABSTRACT FROM AUTHOR]