Late clotted haemothorax after blunt chest trauma.

A clotted haemothorax can develop any time after blunt chest trauma. Two cases are described in which late clotted haemothoraces developed which were treated by limited thoracotomy and evacuation of clots. Late clotted haemothorax may occur even in the absence of any abnormal initial clinical findings. Early detection and treatment is important to avoid the complications of fibrothorax and empyema with permanent pulmonary dysfunction. After blunt chest trauma patients should be advised to return to the accident and emergency department for assessment on development of any new chest symptom. Under these circumstances a chest x ray is mandatory to exclude a haemothorax.     

Emergency ultrasound in the acute assessment of haemothorax

Aims: To evaluate thoracic ultrasound for the detection of haemothorax in patients with thoracic trauma against established investigations.

Methods: Thoracic ultrasound was performed as an extension of the standard focused assessment with sonography for trauma (FAST) protocol used at the Queen's Medical Centre for the assessment of adult patients with torso trauma. Fluid was sought in both pleural cavities using a hand portable ultrasound system by one of two non-radiologists trained in FAST. Findings were compared against subsequent investigations/procedures performed at the discretion of the attending emergency physician—supine chest radiography, intercostal drain, computed tomography, or thoracotomy. The sensitivity of the technique and the time taken to diagnosis for each investigation were recorded.

Results: Sixty one patients, 54 (89%) after blunt trauma, underwent thoracic ultrasound evaluation during the study. Twelve patients had a haemothorax detected by ultrasound and confirmed by computed tomography or by tube thoracostomy. Four haemothoraces detected on ultrasound were not apparent on trauma chest radiography. There were 12 true positives, 48 true negatives, no false positives, and one false negative scan. The sensitivity of ultrasound was 92% and specificity 100% with a positive predictive value of 100% and negative predictive value 98% for the detection of haemothorax after trauma.

Conclusions: Emergency ultrasound of the chest performed as part of the primary survey of the traumatised patient can rapidly and accurately diagnose haemothorax and is a valuable tool to augment the immediate clinical assessment of these patients.

     

Ultrasound-diagnosed cardiac tamponade after blunt abdominal trauma-treated with emergent thoracotomy

Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. We report a case in which blunt trauma to the abdomen and pre-existing pericardial fluid, due to human immunodeficiency virus (HIV), caused pericardial tamponade, diagnosed by bedside ultrasonography, and subsequent cardiac arrest. An ED thoracotomy released this tamponade, and spontaneous cardiac activity returned. The indications for and efficacy of ED thoracotomy have been debated for many years. Multiple studies have shown that patients with isolated penetrating chest trauma have the best outcome and that patients with blunt trauma without signs of life at the scene or in the ED have the poorest. We demonstrate the importance of ultrasound use by emergency physicians to assess trauma patients with pulseless electrical activity and suggest that in specific clinical situations after blunt trauma, an ED thoracotomy can be life saving.     

Detection of occult pneumothoraces in the significantly injured adult with blunt trauma.

BACKGROUND: Identification of pneumothoraces is essential during the initial assessment of major injury. Prompt intervention is crucial for effective resuscitation and for subsequent safe management. Historically, emergency departments have relied on chest X-ray for detection of pneumothoraces. More recently, the increasing availability of computed tomography (CT) has provided a more sensitive means of detection. Occult pneumothoraces are those that are missed on clinical examination and chest X-ray, but are detected on subsequent CT. OBJECTIVE: To determine the incidence of occult pneumothoraces and their impact on subsequent management. PATIENTS: All blunt trauma patients with CT scans from a single, large, adult emergency department in 1 year. METHODS: Patient records were analysed to determine the proportion of pneumothoraces detected on CT that had not been previously detected on chest X-ray. Records were further examined to determine how many occult pneumothoraces required additional management after detection. RESULTS: In all, 134 blunt trauma patients required a CT scan. Thirty-five pneumothoraces were detected in 27 patients; 15 were occult. Six of these 15 were managed with intercostal drain insertion, all proceeding to mechanical ventilation. Of the eight patients (one bilateral) managed observantly, all had uncomplicated recoveries. CT was significantly more sensitive in the detection of pneumothoraces (P=0.03). Retrospective review by a radiology specialist identified three chest X-rays that had findings (deep sulcus sign and prominent cardiac outline) that were suggestive of pneumothorax. CONCLUSIONS: A sufficiently high proportion of pneumothoraces is missed on chest X-ray to advocate a low threshold for use of CT in the early assessment of blunt trauma patients, especially if mechanical ventilation is required for ongoing management.     

Indirect traumatic diaphragmatic rupture

Between 1969 and 1988 51 polytraumatized patients were treated for rupture of the diaphragm due to blunt trauma. In 39 cases the lesion was in the left hemidiaphragm, in 11 cases on the right side and in one case on both sides. Clinical investigation and posterior-anterior chest X-ray were the most important diagnostic procedures. A high percentage of ruptures was only detected intraoperatively during acute laparotomy/thoracotomy. Early or delayed surgery had no influence on the survival of patients. The prognosis depends on the severity of associated injuries, which are the main causes of death in these patients.     

Pelvic and scrotal trauma: CT and triage of patients

Traumatic dislocation of the testicles was first reported during crush injury but is now more commonly related to motor vehicle accidents. Approximately 55 cases had been reported by 2003. Virtually no papers discuss the role of CT in the rapid diagnosis of penoscrotal trauma, although most polytrauma or “pelvic trauma” patients are rapidly evaluated by CT in the emergency room setting. As more patients with pelvic trauma are triaged and evaluated using CT scanners with greater multidetector capability, more patients will be seen with testicular injury. It is important for the emergency physicians, radiologists, and traumatologists not to overlook unsuspected cases of penoscrotal injury which are typically initially evaluated by history, physical exam, and ultrasound. We describe a recent case of initial diagnosis of bilateral testicular dislocation from blunt trauma using modern multidetector CT imaging technique.     

Evaluating blunt abdominal trauma:role for ultrasonography.

Patients in unstable condition with suspected blunt abdominal trauma require rapid evaluation to assess the need for laparotomy. Ultrasonography is fast and uses portable equipment, and it can be used in the resuscitation area to detect free intraperitoneal fluid as an indication of intraabdominal injury in the patient in unstable condition. To determine the utility of emergency abdominal sonography for evaluating patients with blunt abdominal trauma, a prospective study was designed to compare ultrasonography to diagnostic peritoneal lavage. Emergency sonography was performed prior to diagnostic peritoneal lavage on 54 acutely injured patients in the resuscitation area. Our results reveal that ultrasonography has a sensitivity of 87%, a specificity of 100%, and an overall accuracy of 96% for detecting free intraperitoneal fluid. We conclude that ultrasonography is a reliable method for the emergent evaluation of blunt abdominal trauma and can be used in place of diagnostic peritoneal lavage as the initial indicator of significant intraperitoneal injury requiring surgical intervention.     

Sonography as the primary screening method in evaluating blunt abdominal trauma

PURPOSE: The radiological evaluation of patients with blunt abdominal trauma can be done with either ultrasound (US) or computed tomography (CT) with strategies varying considerably among institutions. We evaluated the efficacy of our current strategy in which US is used at our hospital as the primary screening tool for patients with blunt abdominal trauma. METHODS: We retrospectively analysed all patients admitted to our hospital with possible blunt abdominal trauma who underwent abdominal US, abdominal CT and/or a laparotomy during the initial trauma assessment from 1998 until 2002 (n = 1149). RESULTS: Nine-hundred sixty-one of the 1149 patients had a negative US, of which 922 were true negative, resulting in a negative predictive value of 96%. A CT of the abdomen was performed in 7%. In 1.7% there was delayed diagnosis with no significant additional morbidity. Fourteen of the 103 laparotomies (14%) were non-therapeutic; in 5 of these cases the patients underwent non-therapeutic laparotomy despite the performance of a CT. Seven were emergency operations. CONCLUSIONS: In our practice, the use of US for the evaluation of acute blunt abdominal trauma is adequate, with a high negative predictive value, a small number of delayed diagnoses, and an acceptable rate of non-therapeutic laparotomies.     

Serial abdominal ultrasound in the setting of trauma

Ultrasound is gaining wide acceptance in Emergency Medicine as an inexpensive and accurate examination modality. One of the leading uses of this technology is in the initial assessment of the trauma patient, where the ultrasound examination is often used to determine the need for immediate laparotomy or further diagnostic study. We present a series of four patients, all of whom sustained blunt or penetrating abdominal trauma. In each case, the initial screening abdominal ultrasound was negative for free intraperitoneal (i.p.) fluid but, when repeated by the same practitioner, became positive. These cases demonstrate the need for serial ultrasounds in evaluating the patient with abdominal trauma. Future studies of trauma ultrasound should investigate the utility of serial sonographic examinations.     

Emergency thoracotomy

Emergency thoracotomy is a valuable therapeutic modality for the moribund patient when trauma is the cause of the shock state. It is a procedure that requires an understanding of the technique and indications and should be instituted based on the indications listed above. There is probably no reason to do this procedure in the patient who is in extremis as a result of blunt trauma, because results have been universally dismal in these patients. In the patient with a rapidly expanding abdomen resulting from trauma and who is moribund, opening the chest and cross-clamping the aorta may be beneficial. Emergency thoracotomy does not take the place of volume replacement and definitive surgical care for the trauma patient.     

Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum

Objectives: To evaluate non-radiologist performed emergency ultrasound for the detection of haemoperitoneum after abdominal trauma in a British accident and emergency department.

Methods: Focused assessment with sonography for trauma (FAST) was performed during the primary survey on adult patients triaged to the resuscitation room with suspected abdominal injury over a 12 month period. All investigations were performed by one of three non-radiologists trained in FAST. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident and emergency physician. The patients were followed up for clinically significant events until hospital discharge or death.

Results: One hundred patients who had sustained blunt abdominal trauma, were evaluated by FAST. Nine true positive scans were detected and confirmed by computed tomography, diagnostic peritoneal lavage, or laparotomy. There was one false positive in this group, giving a sensitivity of 100%, specificity 99%, and positive predictive value of 90%. Ten patients with penetrating injuries were evaluated with a sensitivity and specificity for FAST of 33% and 86% respectively.

Conclusions: Emergency torso ultrasound for the detection of haemoperitoneum can be successfully performed by trained non-radiologists within a British accident and emergency system. It is an accurate and rapid investigation for blunt trauma, but the results should be interpreted with caution in penetrating injury.

     

The fast is positive,now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

INTRODUCTION: The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination. METHODS: We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention ("therapeutic laparotomy"). We analyzed the variables using binary recursive partitioning analysis to create a decision rule. RESULTS: There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%-80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%-46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%-22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy. CONCLUSION: In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.     

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.     

Assessment, monitoring and emergency nursing care in blunt chest injury: A case study

The case study highlights several complications that commonly develop in trauma patients who sustain blunt chest injuries with underlying lung injury and discusses essential nursing assessment and care. Rib fractures are one of the most common injuries sustained from blunt chest trauma and frequently co-exist with underlying lung injury. Rib fractures alone are associated with high morbidity and mortality. The addition of underlying lung injury such as lung contusions increases the incidence of adverse outcomes. Emergency nursing care must involve thorough assessment and timely intervention with a particular focus on maximising respiratory function and reducing pain. This can be achieved by appropriate oxygen therapy, early chest physiotherapy and adequate analgesic strategies.     

创伤性膈肌损伤50例诊治分析

目的探讨创伤性膈肌损伤的早期诊断与治疗方法。方法对2002年2月至2009年3月收治的50例创伤性膈肌损伤患者的临床资料进行回顾性分析。结果 50例患者均为闭合性损伤,其中交通事故伤23例,高处坠落伤19例,挤压伤8例;术前经X线检查明确诊断23例,经CT检查明确诊断20例,7例经剖胸或剖腹探查时确诊;伤后24 h内手术34例,24 h～48 h手术6例;术前给予抗休克治疗并同时紧急行手术治疗,经胸手术38例,胸腹联合切口手术10例,经腹手术2例。术后发生全身炎症反应综合征(SIRS)导致器官功能障碍综合征(MODS)死亡3例,其余47例手术治疗出院,随访疗效满意。结论早期采用胸部X射线、CT检查结合临床表现综合诊断创伤性膈肌损伤是可行的,及时和正确地给予手术治疗是救治的关键。     

The Risk of Intra‐abdominal Injuries in Pediatric Patients with Stable Blunt Abdominal Trauma and Negative Abdominal Computed Tomography

Objectives: This review examines the prevalence of intra‐abdominal injuries (IAI) and the negative predictive value (NPV) of an abdominal computed tomography (CT) in children who present with blunt abdominal trauma. Methods: MEDLINE, EMBASE, and Cochrane Library databases were searched. Studies were selected if they enrolled children with blunt abdominal trauma from the emergency department (ED) with significant mechanism of injury requiring an abdominal CT. The primary outcome measure was the rate of IAI in patients with negative initial abdominal CT. The secondary outcome measure was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs in those with negative initial abdominal CTs. Results: Three studies met the inclusion criteria, comprising a total of 2,596 patients. The overall rate of IAI after a negative abdominal CT was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The overall NPV of abdominal CT was 99.8% (95% CI = 99.6% to 99.9%). There were five patients (0.19%, 95% CI = 0.08% to 0.45%) who required additional intervention despite their initial negative CTs: one therapeutic laparotomy for bowel rupture, one diagnostic laparotomy for mesenteric hematoma and serosal tear, and three repeat abdominal CTs (one splenic and two renal injuries). None of the patients in the latter group required surgery or blood transfusion. Conclusions: The rate of IAI after blunt abdominal trauma with negative CT in children is low. Abdominal CT has a high NPV. The review shows that it might be safe to discharge a stable child home after a negative abdominal CT. ACADEMIC EMERGENCY MEDICINE 2010; 17:469–475 © 2010 by the Society for Academic Emergency Medicine     

Cardiac arrest associated with aortic valve regurgitation

Blunt chest trauma can cause not only damage to the thoracic cage, but can also injure intracardiac structures including the papillary muscles, chordae tendineae, and valve leaflets. Aortic valve (AV) injury secondary to blunt chest trauma is a rare occurrence. Clinically, AV injury may be missed during the initial post-trauma assessment due to the lack of suspicion of cardiac involvement. Thus, the diagnosis of AV injury is often delayed or missed for a time interval of days to months. As a consequence, the traumatic AV regurgitation can rapidly or progressively lead to congestive heart failure unless surgically corrected. Therefore, emergency physicians should be aware of the possibility of intracardiac structure injury, such as valvular injuries, after blunt chest trauma. Guidelines for the appropriate use of bedside cardiac ultrasound (BCU) recommend BCU should be performed in all patients with new murmurs for clinically significant valvular lesions that could potentially change management.We described the case of a 73-year-old female patient with AV injury after blunt trauma. She experienced cardiac arrest (CA) secondary to a moderate-to-severe traumatic AR, which was successfully treated with emergency AV replacement. We discuss how to diagnose and manage a CA patient, aided by BCU, with ventricular failure associated with persistent AV regurgitation. To the best of our knowledge, this is the first case report on CA associated with isolated rupture of bicuspid AV rupture and AV regurgitation secondary to blunt chest trauma because of the lack of early suspicion of AV injury.     

无口服对比剂急诊CT平扫对闭合性腹部创伤的诊断价值

目的：探讨无口服对比剂急诊CT平扫对闭合性腹部创伤诊断价值。方法：回顾性分析349倒闭合性腹部创伤患者，采用多层螺旋CT无口服对比剂急诊腹盆腔CT平扫的结果，与经临床随访和外科剖腹探查证实的诊断结果进行对比，观察其符合率。结果：CT报告292例阴性，57例阳性，其中7例假阴性和5例假阳性，对闭合性腹部创伤诊断敏感性为91％，特异性为98％，阳性预测值为88％，阴性预测值为98％。结论：无口服对比剂急诊CT平扫可以作为闭合性腹部创伤患者首选影像学检查方法。     

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence‐based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)‐performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. Conclusions: This evidence‐based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma. ACADEMIC EMERGENCY MEDICINE 2010; 17:11–17 © 2010 by the Society for Academic Emergency Medicine     

Chest X-rays in detecting injuries caused by blunt trauma

BACKGROUND: The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma.METHODS: A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009-2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists.RESULTS: Of the 447 patients, 309 (69.1%) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3%) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95%CI 78.3 (63.6-89)] but the lowest in pneuomediastinum [95%CI 11.8 (1.5-36.4)]. The specificity of CXR was close to 100% in detecting a wide array of entities.CONCLUSION: CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.