Assisted respiration using CPAP via face-mask in patients with blunt chest trauma. An alternative to intubation and mechanical ventilation

Summary Intubation and Positive End Expiratory Pressure Ventilation (PEEP) is a well established therapeutic strategy for impaired lung function, particularly following blunt chest trauma. Complications of this regime are however also well known and pose the question why non-invasive forms of respiratory assistance such as Continuous Positive Airway Pressure (CPAP) have only gained minor popularity. In a prospective study, 30 patients who had suffered blunt chest trauma were treated with CPAP administered by mask. The regime consisted of continuous administration of CPAP by a face-mask, with gradually increasing periods of spontaneous breathing. Initially a FiO₂ of 0.33 (range 0,28–0,38) proved necessary. The initial CPAP level was 7 mbar (range 5–8) with an (Assisted Spontaneous Breathing) ASB of 15 mbar (range 13–18). FiO₂ and CPAP/ASB levels were subsequently gradually reduced until no longer necessary. In all patients intubation and ventilation was avoided by this regimen. The treatment was well accepted by all patients and common ventilation associated complications such as pneumonia did not occur. In comparison with the former standard method of treatment the average ICU stay was dramatically reduced, principally due to not having to gradually wean patients from ventilation and sedation. Other positive benefits include normal communication and feeding with active early mobilisation leading to faster recovery, both physical and psychological. We conclude that non-invasive respiratory techniques should be used more frequently and recommend further studies are undertaken to define the indications.      

Blunt chest trauma in childhood

BACKGROUND: Although thoracic injuries are uncommon in children, their rate of morbidity and mortality is high. The aim of this study was to evaluate the clinical features of children with blunt chest injury and to investigate the predictive accuracy of their paediatric trauma scores (PTS). METHODS: Between September 1996 and September 2006, children with blunt thoracic trauma were evaluated retrospectively. Clinical features and PTS of the patients were recorded. RESULTS: There were 27 male and 17 female patients. The mean age was 7.1 +/- 3.4 years, and the mean PTS was 7.6 +/- 2.4. Nineteen cases were injuries caused by motor vehicle/pedestrian accidents, 11 motor vehicle accidents, 8 falls and 6 motor vehicle/bicycle or motorbike accidents. The following were noted: 28 pulmonary contusions, 12 pneumothoraxes, 10 haemothoraxes, 9 rib fractures, 7 haemopneumothoraxes, 5 clavicle fractures and 2 flail chests, 1 diaphragmatic rupture and 1 pneumatocele case. The cut-off value of PTS to discriminate mortality was found to be < or = 4, at which point sensitivity was 75.0% and specificity was 92.5%. Twenty-seven patients were treated non-operatively, 17 were treated with a tube thoracostomy and two were treated with a thoracotomy. Four patients who suffered head and abdominal injuries died (9.09%). CONCLUSION: Thoracic injuries in children expose a high mortality rate as a consequence of head or abdominal injuries. PTS may be helpful to identify mortality in children with blunt chest trauma. Blunt thoracic injuries in children can be treated with a non-operative approach and a tube thoracostomy.     

Misleading symptoms after a minor blunt chest trauma

We present a case of missed diaphragmatic rupture which was treated thoracoscopically. Rupture of the diaphragm is a serious complication of blunt trauma. The diaphragmatic injury can easily be overlooked. This report illustrates the diagnostic dilemma in a patient where the injury was missed at the time of initial presentation. The role of thoracoscopy both for diagnosis and therapy is discussed. Received: 24 January 1997/Accepted: 2 April 1997     

Expectant management of blunt renal trauma

Summary Forty-two patients with blunt renal injuries were treated between 1984 and 1994 at our institution. Twenty-nine patients revealed a contusion (grade I injury), 10 showed lacerations (grade II), 1 a severe fracture (grade III), and 2 presented pedicle injuries (grade IV). All 10 patients with incomplete renal injuries (grade II) were treated conservatively, i. e. without primary surgery. One of these 10 patients required surgical intervention 3 months after the trauma due to a urinary obstruction. Two of the ten patients with grade II injuries suffered late complications, namely a contracted kidney in one case and hypertension in the other. This means that of 10 patients with conservatively treated grade II renal trauma, a loss of the function of the affected kidney occurred in only one. In 9 patients complete function of the kidney could be preserved. In conclusion, conservative management of incomplete blunt renal injuries is an effective treatment option with few complications.      

Comparison of multiple trauma in children and adults

Summary Multiple injuries in children are responsible for a great part of childhood mortality. Remaining handicaps after injuries have a social and economic significance. In this study, the characteristics of polytrauma in childhood are evaluated by comparison with severely injured adults. The two groups of multiple trauma patients (117 children between 3 and 15 years of age and 1159 adults between 16 and 59) were equal in the overall severity of all injuries. Children were mainly hurt as pedestrians, whereas adults had an accident more often as car passengers. The most frequently injured region were in both groups fractures of the extremities. The greatest injury severity represented head injuries in each group. Complications were seen more often in adult patients. Multiple organ failure and isolated liver failure were exclusively seen in the adult group, pneumonia and lung failure occurred significantly more often. The duration of artificial ventilation and the duration of hospital stay were prolonged in the adult group. In summary, children with multiple injuries have a lower mortality rate than adults. The main cause of death are cerebral injuries. Remaining handicaps in surviving children are most often caused by fractures of the lower extremities.      

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.     

Occult pneumomediastinum in blunt chest trauma: Clinical significance

Introduction

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or “overt pneumomediastinum”, raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or “occult pneumomediastinum”. Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population.

Methods

A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated.

Results

Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p < 0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p < 0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam.

Conclusion

Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.     

Bronchoscopy in severe blunt chest trauma

Summary Extended lesions of the lung parenchyma are often seen in association with blunt chest trauma. Blood aspiration, atelectasis and the formation of bronchopleural fistulae can lead to early respiratory deterioration and the development of severe post-traumatic complications (pneumonia, acute respiratory distress syndrome). Diagnostic and therapeutic bronchoscopy is essential on admission. This procedure helps to estimate the severity and extent of parenchymal lesions even before chest X-ray signs are noted. Bronchoalveolar lavage is needed for removal of aspirates. In our study bronchoalveolar lavage on admission reduced bacterial contamination and pneumonia in comparison to patients not lavaged. A new method for closure of bronchopleural fistulae is described. Fibrin instillation after balloon catheter occlusion leads to a significant reduction of tidal volume loss (greater than 50% in average).     

Blunt thoracic trauma

The restructuring of emergency healthcare services has led to more blunt thoracic trauma being treated by a multidisciplinary team, including general, orthopaedic and trauma surgeons, often without immediate access to a thoracic surgeon. Having a critical mass of injured patients in a central location, it has been possible to bring expertise from other areas of intensive care, radiology and surgery and apply new technology and techniques to the trauma patient. We now see the regular use of endovascular stenting and embolization reducing the need for urgent surgery on unstable patients and the increasing use of extracorporeal membranous oxygenation (ECMO) to salvage patients with acute respiratory distress syndrome. A more liberal use of video-assisted thoracic surgery (thoracoscopic) decortication and chest wall fixation both reduce ICU requirements and shorten hospital stay. It is hoped that these improvements in the hospital management of chest injuries will not only improve survival, but that the reduction in the late sequelae of chronic pain and loss of stamina will translate into improved return-to-work rates.     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Blunt thoracic trauma

Blunt thoracic trauma (BTT) accounts for 98% of thoracic trauma and can be isolated or part of the polytrauma. There are two well-defined strata of patients who present with BTT.The first group are patients with high-energy injuries which tend to have multi-trauma and are critically ill. The aim in managing these patients is to identify life-threatening underlying injuries and stabilize the patients as much as possible prior to referring to thoracic surgery. Occasionally, the need for urgent surgery by a thoracic surgeon is required, but in most cases minor procedures which can be performed in the emergency department (ED) of a district general hospital are warranted as a first measure prior to transferring the patient. The second group are the patients with isolated low-energy thoracic trauma with rib fractures and some underlying complications. The treatment of these patients tends to concentrate on respiratory support and effective analgesia and secretion clearing strategies. Increasingly there is a trend to perform surgical fixations for multiple rib fractures to achieve better analgesia and faster recovery, and to prevent prolonged ventilation. This article offers guidance on the management of patients with blunt chest trauma prior to referring to thoracic surgery.     

The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

INTRODUCTION: Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. METHODS: A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. RESULTS: The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p<0.001), reduced air-entry (OR=4.48, 95% CI=1.33, 15.02, p=0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p=0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. CONCLUSION: In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.     

Tracheoesophageal fistula in a child after blunt chest trauma

Traumatic tracheoesophageal fistula is a rare complication after blunt chest trauma, with all reported cases being more than 12 years of age. We report a 5-year-old boy with traumatic tracheoesophageal fistula after a blunt injury to the chest.     

Blunt liver trauma in children: nonoperative management

Since 1978, we have treated 19 of 23 (83%) children with blunt liver trauma nonoperatively. Management consisted of observation in an intensive care unit, repeated physical examination, frequent reevaluation of laboratory values, special investigations, and bed rest. The 19 patients all remained stable, required no surgical intervention, and showed resolution of the hepatic injuries with no early or delayed complications. Ultrasonography, although not as reliable a method as computed tomography or liver isotope scans for identification of hepatic trauma at first presentation, provided a very useful method for documenting subsequent progress and eventual healing of the lesions. The presence of an isolated hepatic injury is insufficient indication for surgery. If there is significant extrahepatic injury requiring surgery, or if the patient with hepatic trauma is deteriorating, operative intervention is mandatory.     

Atrioventricular septal defect following blunt chest trauma

The authors describe an acquired atrioventricular septal defect that has resulted from a blunt chest trauma. Besides being an uncommon traumatic heart injury, this case has the particularities of the non-involvement of other adjacent anatomical structures and the long delay between the accident and the occurrence of the myocardial rupture.     

Tracheobronchial Rupture due to Blunt Chest Trauma: Report of a Case

Tracheobronchial injuries following blunt chest trauma are uncommon in children. The involvement of both the trachea and right main bronchus separately is highly unusual. We herein report the case of a 13-year-old boy who presented with both a tracheal and right main bronchial rupture following blunt chest trauma. While the tracheal laceration required a tracheotomy, a delayed repair of right main bronchial disruption was performed with a complete preservation of the right lung. The features of this uncommon entity are discussed, with special emphasis on early diagnosis and surgical management.     

Blunt hepatic trauma in children: experience with operative and nonoperative management

Between 1974 and 1982, 32 children were treated for blunt hepatic trauma. Twenty-three injuries were secondary to motor vehicle accidents. Twenty-three patients had associated injuries. The hepatic injury was treated surgically in 18 patients. Urgent surgery for massive bleeding was required in 7 patients; 8 underwent laparotomy for continued bleeding after initial stabilization; 2 underwent laparotomy for marked abdominal tenderness, and 1 for an expanding hepatic hematoma. Various excisional, debridement, suture, and drainage procedures were employed. Seven patients died, 5 from uncontrollable bleeding and 2 from associated severe head injury. The eleven survivors did well. The only postoperative complications were two wound infections. Fourteen patients were managed nonoperatively. Liver scan provided the diagnosis in all. Five of these patients required blood transfusion, and the mean volume of transfusion was 33cc/kg. The hospital courses in all cases were uneventful, and there were no late complications. A follow-up liver scan was obtained in 11 patients, showing resolution of the injury in all. We conclude that laparotomy is necessary for hepatic injury when it is associated with continuous massive bleeding. Hemodynamically stable patients can be managed nonoperatively, even when the blood-transfusion requirements are significant.     

International comparison of the treatment of polytraumatized patients

Summary Worldwide there will be an increase in polytraumatized patients. The number of death after trauma will increase from 5,1 Mill. to 8,4 Mill. The reason is the technical progress in the third world. In western countries there was a decrease in trauma death, in Germany below 8.000 due to traffic accidents in 1998. In most countries the paramedic system and ATLS are established (USA, South Africa). Long rescue times and inadequate shock treatment preclinically are the bigest problems in Russia and Greece. Worldwide the institution of trauma centers (Level I, II, III) has brought much better results comparing to nontrauma centers but is economically expensive. The annual number of polytraumatized patients (Level I 600–1.000 severe trauma, > 65 personal experience) is essential for the success rate. Infrastrucure, Algorithmus and the personal experience of the trauma leader are the keys for optimal results. One parameter for Quality measurement is the number of potentially preventable deaths. Retrospective analysis of treatment protocols and pathological results by an expert team is the best practical way. The results of level I trauma teams reach between 1 and 2 % preventable deaths. A further instrument of quality improvement are Trauma registers like in US and England (MTOS) and the German Trauma register of the German Society of Trauma. The Trauma register in Germany contents till now 2.069 polytraumatized patients.The lethality is 18,6 % (ISS 21 ± 13), comparing to MTOS (ISS 12,8 ± 11,3, lethality 9,2 %). The differences in injury pattern show in the US three times more penetrating injuries than in the German Traumaregister (21,1 % versus 7,2 %).      

Management of polytraumatized patients with associated blunt chest trauma: a comparison of two European countries

BACKGROUND: Blunt chest trauma represents one of the most common injuries in polytrauma patients. Blunt chest injury complicating polytrauma is associated with significant prolongation of intensive care stay. Further, it has a great impact on the timing of fixation of skeletal injuries, possibly contributing to adverse outcome. The purpose of this study is to assess whether there are any differences in the management and outcome of polytrauma patients with blunt chest trauma between trauma units in two different countries. Detailed information about advantages and disadvantages of these two systems might allow optimising the management of blunt chest trauma. PATIENTS AND METHODS: This investigation was performed using the polytrauma database of the German Trauma Society and the British Trauma Audit Research Network. After the definition of the inclusion abbreviated injury scale (AIS(chest) > or = 3) and injury severity score (ISS > 16) and exclusion (AIS(head/neck) > or = 2, referral from outside institutions) criteria, patients were recruited solely from these databases. RESULTS: 188 patients from the German database and 181 patients from the British database were enrolled in this study. Demographic data and injury pattern of the two patient populations did not significantly differ. The volume of initial red blood cell transfusion and length of the intensive care stay were significantly higher in Germany (p < 0.05). Mortality in the UK was 9% higher than in Germany (p = 0.057). Time to death in non-survivors was also significantly longer in Germany (p < 0.05). CONCLUSIONS: The reasons for the differences regarding survival times and survival rates seem to be multiple. German patients received more red blood cells, had a longer hospital stay in intensive care and a better survival rate. The use of kinetic therapy in Germany, not standard in the UK, may contribute to a more favourable outcome.     

Sudden death from contusion of the right atrium after blunt chest trauma: case report and review of the literature

Occult cardiac injury following blunt trauma is more common than generally suspected. Myocardial lesions range from myocardial contusion to cardiac rupture. Myocardial contusion is not uncommon, it is usually a benign disorder which often remains undiagnosed. We report the case of a previously healthy 29-year-old man who was involved in a fight and suffered from blunt heart injury leading to contusion of the right atrium. The patient died soon after the injury and before admission to the Hospital. The diagnosis was made at autopsy. The present case is of special interest because of the unusual eliciting event and the rarity of the contusion site (right atrium). It is reported in order to raise the index of suspicion in physicians treating patients involved in a fight and aid in prompt diagnosis of myocardial contusion.