FAST (Focused Assessment With Sonography in Trauma) Accurate for Cardiac and Intraperitoneal Injury in Penetrating Anterior Chest Trauma

Objective. To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. Methods. An observational prospective study was conducted over a 30‐month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. Results. FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%–100%); specificity was 100% (95% confidence interval, 85.8%–100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%–99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%–100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false‐positive results, giving a specificity of 100% (95% confidence interval, 85.8%–100%). This prompted necessary laparotomy in all 8. Conclusions. In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.     

Thoracic vertebrae fracture: Is it an indicator of abdominal injury?

PurposeTraumatic vertebral fracture accounts for 10–15% of trauma related admissions. While the correlation between lumbar vertebral fractures and abdominal injuries is well established, the relationship between thoracic vertebral fractures (TVF) and abdominal injuries is comparatively less well elucidated. Using a large national trauma database, we aimed to examine the incidence and severity of associated abdominal injuries in blunt trauma patients suffering from TVF.MethodsA retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic vertebrae spine fractures following blunt mechanisms of trauma between 1997 and 2018 were examined, comparing the incidence and severity of associated intraabdominal organs injuries with and without TVF. Demographics and outcomes between the two cohorts were compared.ResultsFrom 362,924 blunt trauma patients, 4967 (1.37%) had isolated TVF. Mean age was 49.8 years and 61.9% were males. The most common mechanism of injury was fall following by MVC. The patients with TVF had significantly higher rates of increased ISS score (ISS > 16, 28.45% vs. 10.42%, p < 0.001) and higher mortality rate (3.5% vs. 2%, p < 0.0001). Patients with TVF had 2–3 times more intraabdominal organ injuries (p < 0.001). The most commonly injured organ was spleen (3.28%); followed by liver (2.64%) and kidney (1.47%).An analysis of non-isolated thoracic spine fractures showed same distribution in age, ISS, mechanisms, patterns of intra-abdominal injury, mortality rate and laparotomy rate.ConclusionClinicians should have an elevated suspicion for intra-abdominal injuries when a thoracic spine fracture is identified, which may necessitate further evaluation.     

Rare right ventricular myxoma detected incidentally on a FAST examination

A young man underwent Focused Assessment with Sonography in Trauma (FAST) scan for blunt abdominal trauma. An incidental finding on the pericardial view was the presence of a tumor in the right ventricle. Detailed cardiac imaging and subsequent excision revealed the presence of a myxoma. The patient had no obvious cardiac symptoms, but the awareness and experience of the examiner during the FAST examination detected this rare heart tumor at a latent stage, preventing serious, irreversible complications. This case demonstrates the potential importance of looking above the diaphragm during routine abdominal sonography, especially in patients who are critically ill.     

Clinical predictors of injuries not identified by focused abdominal sonogram for trauma (FAST) examinations

This study's objective was to identify clinical characteristics of patients with a blunt traumatic injury that increased the risk of peritoneal or pericardial fluid collections and abdominal organ injuries not identified by a bedside focused abdominal sonogram for trauma (FAST) examination. This observational study used a retrospective chart review of a cohort of patients identified through a query of the University of Nebraska Medical Center's trauma registry, a tertiary referral center for portions of Nebraska, Iowa, and Missouri. Adult patients presenting to the Emergency Department (ED) for an evaluation of blunt traumatic injury from September 1996 to December 2002 were eligible if their ED course included admission to the trauma service after completion of a bedside FAST examination (US) and a confirmatory study (Conf) such as an abdominopelvic computed tomography scan or exploratory laparotomy within 12 h of completion of the ED FAST examination. The medical records of those patients with a US+/Conf+ or US-/Conf+ examination were reviewed. Clinical characteristics were recorded on a standard data collection form. Statistically significant predictors of a US-/Conf+ examination were found using a stepwise logistic regression procedure. A query of the trauma registry for the study period revealed 1453 adult individuals with blunt abdominal trauma, with 458 patients meeting the inclusion criteria. The clinical characteristics of the 79 US+/Conf+ examinations were compared to those of the 53 US-/Conf+ examinations. The presence of a radiographically proven pelvic fracture (odds ratio 3.459; 95% confidence interval of 1.308-9.157) and a radiographically or operatively proven renal injury (odds ratio 3.667; 95% confidence interval of 1.013-13.275) were found to be significant predictors. The presence of a pelvic fracture or renal injury in adult victims of blunt abdominal trauma increases the likelihood of a US-/Conf+ examination. Patients with a negative FAST examination and pelvic fracture may benefit from additional radiographic or operative evaluations for occult injuries.     

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

Introduction

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

Patients and methods

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

Results

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

Conclusions

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.     

Throws of Death: Traumatic Coronary Artery Dissection Resulting From Jiu Jitsu Training

BackgroundThe risk of cardiac injury in blunt thoracic trauma is quite rare, occurring in only 0.1% of patients. The least common cardiac injury is coronary artery dissection. Most cardiac injuries result from high-energy mechanisms such as motor vehicle collisions. Even low-mechanism injuries that have been reported involved rapid deceleration.Case ReportWe present a case of traumatic coronary artery dissection that resulted from a low-energy blunt thoracic injury with no rapid deceleration. This patient had no other associated thoracic injuries, such as rib fractures or sternal fracture. Following presentation, our patient twice deteriorated into ventricular fibrillation and was successfully resuscitated each time. The coronary lesion was successfully stented and the patient was eventually discharged home.Why Should an Emergency Physician be Aware of This?This case underscores the importance of maintaining a high level of suspicion for coronary artery dissection even in low-energy mechanisms. An electrocardiogram should be obtained early, even in low-energy mechanisms. While patients with traumatic cardiac injuries will commonly present with other injuries, such as rib fractures, the absence of these injuries does not rule out cardiac injury.     

Scapular Fractures in the Pan‐scan Era

Background

Scapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary contusion, and rib fracture, increased chest computed tomography (CT) utilization and head‐to‐pelvis CT (pan‐scan) protocols in blunt trauma evaluation, however, may diagnose minor, clinically irrelevant scapular fractures, possibly rendering previous teachings obsolete.

Objectives

The objectives were to determine the 1) percentages of scapular fractures seen on chest CT only (SOCTO) versus seen on both chest x‐ray (CXR) and CT and of isolated scapular fracture (scapular fracture without other thoracic injuries); 2) frequencies of associated thoracic injury with scapular fracture; and 3) proportion of patients admitted, mortality, hospital length of stay, and injury severity scores (ISS), comparing four patient groups: scapular fracture, nonscapular fracture, scapular fracture SOCTO, and isolated scapular fracture.

Methods

We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest CT study at nine Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation.

Results

Of 11,477 subjects, 4,501 (39.2%) patients who had both CXR and chest CT and 2.7% of these had scapular fractures; 60.3% of these were SOCTO and 23 (19.0%) were isolated scapular fracture. The most commonly associated thoracic injuries were rib fracture, pulmonary contusion, pneumothorax, and thoracic spine fracture and all injuries were more common in scapular fracture patients than nonscapular fracture patients. Although scapular fracture patients had higher admission rates (86.8% vs. 47.4%; difference in proportions = 39.4% [95% confidence interval {CI} = 32.8% to 44.1%]), ISS (21 vs. 5), and length of stay (9.2 days vs. 5.6 days; mean difference = 3.4 days [95% CI = 2.1 to 4.7 days]) than patients without scapular fracture, their hospital mortality was not significantly different (5.6% vs. 3.0%; difference in proportions = 2.6% [95% CI = –8.2% to 0.3%]; unadjusted odds ratio = 1.9 [95% CI = 0.9 to 4.2]). Patients with scapular fracture SOCTO and isolated scapular fracture had higher admission rates and median ISS than nonscapular fracture patients, but their mortality was similar.

Conclusions

Under current blunt trauma imaging protocols that commonly include chest CT, most scapular fractures are SOCTO and most are associated with other thoracic injuries. Although patients with scapular fracture SOCTO and isolated scapular fracture have higher admission rates and ISS than nonscapular fracture patients, their hospital mortality is similar.

     

Association between a positive ED FAST examination and therapeutic laparotomy in normotensive blunt trauma patients

Although a positive FAST (focused assessment with sonography for trauma) examination in hypotensive blunt trauma patients generally suggests the need for emergent laparotomy, this finding's significance in normotensive trauma patients is unclear. We tested the association between a positive FAST and the need for therapeutic laparotomy in normotensive blunt trauma patients. This was a retrospective cohort analysis of consecutive normotensive blunt trauma patients presenting to two trauma centers. The outcome was therapeutic laparotomy. The unadjusted association between a positive FAST and laparotomy was odds ratio (OR) 116 (95% confidence interval [CI] 49.5-273). This association persisted after adjusting for confounding variables (OR 44.6, 95% CI 1.77-1124). Thirty-seven percent of patients with a positive FAST required therapeutic laparotomy vs. 0.5% with a negative FAST. Among normotensive blunt trauma patients, there was a strong association between a positive FAST and the need for therapeutic laparotomy. Very few normotensive patients with a negative FAST required therapeutic laparotomy.     

Non-surgical management in hemodynamically unstable blunt traumatic pericardial effusion: A feasible option for treatment

Introduction

Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hospital alive with blunt traumatic pericardial effusion.

Utility of the Cardiac Component of FAST in Blunt Trauma

Background

Focused assessment with sonography in trauma (FAST) is widely used and endorsed by guidelines, but little evidence exists regarding the utility of the cardiac portion in blunt trauma. The traditional FAST includes the routine performance of cardiac sonography, regardless of risk for hemopericardium.

Study Objectives

Our goal was to estimate the prevalence of hemopericardium due to blunt trauma and determine the sensitivity of certain variables for the presence of blunt hemopericardium.

Methods

We performed a retrospective chart review of two institutional databases at a large urban Level I trauma center to determine the prevalence of blunt hemopericardium and cardiac rupture and incidental or insignificant effusions. We evaluated the sensitivity of major mechanism of injury, hypotension, and emergent intubation for blunt hemopericardium and cardiac rupture.

Results

Eighteen patients had hemopericardium and cardiac rupture (14 and 4, respectively) out of 29,236 blunt trauma patients in the Trauma Registry over an 8.5-year period. The prevalence was 0.06% (95% confidence interval [CI] 0.04–0.09%). The prevalence of incidental or insignificant effusions was 0.13% (95% CI 0.09–0.18%). One case of blunt hemopericardium was identified in the emergency ultrasound database out of 777 cardiac ultrasounds over a 3-year period. No patient with blunt hemopericardium or cardiac rupture presented without a major mechanism of injury, hypotension, or emergent intubation.

Conclusion

Blunt hemopericardium is rare. High-acuity variables may help guide the selective use of echocardiography in blunt trauma.     

Echocardiogram in sternal fracture

We reviewed the records of 50 consecutive patients presenting with sternal fracture after blunt chest trauma. The relationships between electrocardiogram, creatine kinase MB isoenzyme and echocardiogram (ECHO) were assessed in reference to myocardial contusion. Eleven patients (22%) had 1 or more abnormal cardiac tests but only 3 (6%) had clinically symptomatic myocardial contusion. Seven (22.5%) out of 31 ECHO studies revealed pericardial effusion which was not associated with the severity of all other associated injuries. The incidence of an abnormal ECHO study in patients with isolated sternal fracture was similar to that of patients who suffered multiple injuries. In 5 patients with pericardial effusion, this finding was not associated with any other abnormal tests and was regarded as of no clinical cardiac significance. On the other hand, a myocardial contusion was shown by ECHO examination only while echocardiogram and creatine kinase MB tests remained normal in that patient. We suggest that the ECHO should be used as a diagnostic and triage tool in every patient with sternal fracture associated with other injuries. However, patients with "benign" pericardial effusion can be discharged as soon as their medical condition improves regardless of other associated injuries.     

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans

Objective: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians’ Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians’ confidence in using FAST findings to assist in managing patients with blunt trauma. Methods: This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post‐training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26–50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a ‘normal’ FAST was calculated and compared. Results: Accuracy was greatest in group C. Sixty‐nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92–100%). Eighty‐two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15–34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001). Conclusions: FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.     

Definitive management of near-hanging at major versus non-major trauma centres

Objectives

The Victorian State Trauma System recommends that all major trauma patients receive definitive care at a major trauma service (MTS). The aim of the present study was to assess the outcomes of patients with major trauma after near-hangings who received definitive management at an MTS compared to a non-MTS.

Methods

This was a registry-based cohort study of all adult (age ≥16 years) patients with near-hanging included in the Victorian State Trauma Registry from 1 July 2010 to 30 June 2019. Outcomes of interest were death at hospital discharge, time to death and extended Glasgow Outcome Scale (GOSE) score of 5–8 (favourable) at 6 months.

Results

There were 243 patients included and 134 (55.1%) in-hospital deaths. Among patients presenting to a non-MTS, 24 (16.8%) were transferred to an MTS. There were 59 (47.6%) deaths at an MTS and 75 (63.0%) at a non-MTS (odds ratio [OR] 0.53; 95% confidence interval [CI] 0.32–0.89). However, more patients were managed at a non-MTS after out-of-hospital cardiac arrest (58.8% vs 50.8%) and less patients had serious neck injury (0.8% vs 11.3%). After adjustment for out-of-hospital cardiac arrests and serious neck injury, management at an MTS was not associated with mortality (adjusted OR [aOR] 0.61; 95% CI 0.23–1.65) or favourable GOSE at 6 months (aOR 1.09; 95% CI 0.40–3.03).

Conclusions

After major trauma sustained from near-hanging, definitive management at an MTS did not offer a mortality benefit or better functional outcomes. Consistent with current practice, these findings suggest that most near-hanging related major trauma patients could be managed safely at a non-MTS.     

Clopidogrel increases bleeding complications in patients undergoing heart rhythm device procedures

Background: Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving clopidogrel at the time of cardiac device surgery. Methods: We performed a retrospective case‐control study. Between 2004 and 2010, 101 consecutive patients receiving clopidogrel underwent cardiac device surgery (pacemaker or implantable cardioverter–defibrillator implantation, and generator replacement) in our institution. Controls were 1:1 matched on age, sex, device, type of procedure, number of leads implanted, and venous approach (cephalic or subclavian). A significant bleeding complication was defined as pocket hematoma requiring surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion, or tamponade. Results: Bleeding complications occurred more frequently in patients receiving clopidogrel at the time of device procedure: 11.9% versus 4.0% (P = 0.037; odds radio [OR] 3.27 [1.02–10.5]). Significant bleeding complications were noted in 12 patients (11.9%) receiving clopidogrel, including two patients with pericardial effusion and one patient with hemothorax. Four controls (4.0%) had bleeding complications (three pocket hematomas and one pericardial effusion). The single factor associated with increased bleeding complications in patients receiving clopidogrel was subclavian puncture (P = 0.008). In the entire cohort (n = 202), multivariate analysis identified two independent predictors of significant bleeding complications: clopidogrel treatment at the time of surgery (P = 0.03; OR 3.7 [1.1–12.6]) and subclavian venous puncture (P = 0.03; OR 3.44 [1.1–10.4]). Conclusions: Clopidogrel treatment at the time of heart rhythm device procedures is associated with an increased risk of significant bleeding complications. Subclavian puncture seems to strongly increase hemorrhagic complications in this setting. (PACE 2012; 1–7)     

What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?

BackgroundComputed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant.Study ObjectivesThis study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel.MethodsPatients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance.ResultsOf 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries—primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT.ConclusionChest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management.     

Predictors of return visits to the emergency department among different age groups of older adults

ObjectiveTo identify predictors of 30-day emergency department (ED) return visits in patients age 65–79 years and age ≥ 80 years.MethodsThis was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65–79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines.ResultsA total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65–79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65–79: CHF aOR 1.36 [CI 1.16–1.59], dementia aOR 1.27 [CI 1.07–1.49], prior hospitalization aOR 1.36 [CI 1.19–1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13–1.55], dementia aOR 1.22 [CI 1.04–1.42], and prior hospitalization aOR 1.27 [CI 1.09–1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64–0.80] for age 65–79 years and 0.72 [CI 0.63–0.82] for age ≥ 80).ConclusionAge alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.     

Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss?

BackgroundAlthough chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury.MethodsWe analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification.ResultsOf 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6–80.4%), specificity of 86.2% (95% CI 85.1–87.2%), negative predictive value of 98.3 (95%CI 97.9–98.6%), and positive predictive value of 24.7 (95%CI 22.9–26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8–47.9%), specificity of 96.6% (95% CI 95.9–97.2%), negative predictive value of 78% (95% CI 77.2–78.8%), and positive predictive value of 86.9% (95% CI 84.5–89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%).ConclusionsWhen used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.     

Triage in the trauma bay with the focused abdominal sonography for trauma (FAST) examination

Bedside ultrasonography has been applied to the evaluation of blunt trauma patients for over a decade. The Focused Abdominal Sonography for Trauma (FAST) examination has been used to successfully triage blunt trauma patients. Although not traditionally thought to be as useful in penetrating trauma patients, ultrasound can help determine the extent of injury especially of the heart. We present two cases of multiple-stabbing victims who arrived at our Level I trauma center at the same time, when our trauma system was particularly overburdened by multiple consecutive traumas. The FAST examination helped us to accurately determine which of the two patients required operative intervention first, despite that patient's appearance of relative hemodynamic stability in comparison to the other stabbing victim.     

Cardiac luxation: an unusual complication of a log roll

Cardiac luxation is a rare but potentially fatal consequence of blunt thoracic trauma. We present a case of a pericardial tear with cardiac luxation following blunt chest trauma. It is hypothesised that the cardiac luxation occurred while log rolling the patient during the initial assessment. This report stresses the need to be aware of the potential for such a complication.     

Metabolic Syndrome and COVID-19 Mortality Among Adult Black Patients in New Orleans

OBJECTIVECoronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity, and diabetes. We examined the association between hypertension, obesity, and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak.RESEARCH DESIGN AND METHODSData were collected from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, LA, from 30 March to 5 April 2020. MetS was identified per World Health Organization criteria.RESULTSAmong 287 patients (mean age 61.5 years; female, 56.8%; non-Hispanic Black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR] 3.42 [95% CI 1.52–7.69]), intensive care unit requirement (ICU) (aOR 4.59 [CI 2.53–8.32]), invasive mechanical ventilation (IMV) (aOR 4.71 [95% CI 2.50–8.87]), and acute respiratory distress syndrome (ARDS) (aOR 4.70 [95% CI 2.25–9.82]) compared with non-MetS. Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR 2.18 [95% CI 1.25–3.81]), ARDS (aOR 2.44 [95% CI 1.28–4.65]), and IMV (aOR 2.36 [95% CI 1.33–4.21]). Diabetes was associated with ICU (aOR 2.22 [95% CI 1.24–3.98]) and IMV (aOR 2.12 [95% CI 1.16–3.89]). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, CRP and lactate dehydrogenase (LDH), were associated with mortality (CRP [aOR 3.66] [95% CI 1.22–10.97] and LDH [aOR 3.49] [95% CI 1.78–6.83]).CONCLUSIONSIn predominantly Black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as MetS increased the odds of mortality compared with these comorbidities individually.