Saved by the Clot in Superior Vena Cava Injury.

Penetrating neck injuries (PNIs) can cause injuries to great vessels. Superior vena cava (SVC) injury from a stab to the neck is rare and when it occurs, poses a significant risk of exsanguinating hemorrhage. We report a case of a 17-year female who survived a delayed presentation of five hours after sustaining stab injury to zone 1 of the neck. Her external wound was just above the medial 1/3rd of the clavicle which resulted in SVC laceration. Mechanism and site of injury along with clinical presentation with right hemothorax was highly suspicious for a vascular injury. Exsanguinating hemorrhage was halted by a soft clot in this hypotensive patient. Furthermore, permissive hypotension with judicious resuscitation stabilised the patient enough to undergo a contrast venogram to identify the level of SVC injury. The patient underwent successful surgical repair of SVC. This case illustrates the point that control of bleeding by soft clots does not rule out major vascular injury. Additionally, it demonstrates how permissive hypotension can be helpful as a damage control stepping stone in the management of these critical patients. Key Words: Penetrating neck injury, Permissive hypotension, SVC laceration, Venorrhaphy.

Video Assisted Thoracoscopy as a therapeutic modality in evacuating retained or clotted haemothoraces.

OBJECTIVE: To determine the role of video-assisted thoracoscopy for evacuating retained / clotted haemothoraces to minimise the duration of chest tube drainage and length of hospital stay. METHODS: The prospective cohort study was conducted from July 2019 to February 2020 at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, and comprised consecutive patients who underwent video-assisted thoracoscopy for retained or clotted haemothoraces. Outcome was measured as evacuation of retained haemothoraces resulting in partial or complete lung expansion and length of hospital stay. Data was analysed using SPSS 22. RESULTS: Of the 160 patients, 128(80%) were males and 32(20%) were females. The overall mean age was 36.08±11.91 years. Overall, 103(64.37%) patients underwent the procedure in within 4-7 days, and 57(35.63%) within 8-14 days. Complete lung expansion was achieved in 95(71.9%) patients when the procedure was performed in the first week, and in 37(28.1%) when performed in the second week (p=0.01). Within the first week, 87(84.4%) patients had shorter duration of stay compared to patients having undergone the procedure in the second week (p=0.001). Relapse of collection was found in 21(13.7%) patients. CONCLUSIONS: Video-assisted thoracoscopy was found to be a safe, reliable and effective technique for the evacuation of retained haemothorax in haemodynamically stable patients. Early intervention resulted in better outcome.

Role of Anti-Tuberculous Treatment in the Outcome of Decortication for Chronic Tuberculous Empyema.

INTRODUCTION: Chronic tuberculous empyema (CTE) is a common complication of tuberculosis that requires some form of surgical intervention along with anti-tuberculosis therapy (ATT). The aim of this study was to determine the optimum duration of pre-operative ATT in CTE prior to the decortication and its outcomes. MATERIAL AND METHODS: This comparative prospective study was conducted from August 2019 to August 2020 in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. A total of 70 patients were included in the study. They were grouped into two arms: patients operated at or within six weeks of ATT commencement (Group A) and patients operated after six weeks of ATT (Group B). Both groups had 35 participants each. Patients were evaluated based on a self-administered questionnaire. A p-value of less than 0.05 was considered significant. RESULT: In this study, there were 55 (78.6%) males and 15 (21.4%) females with a mean age of 33.5 ± 11.2 years. Diagnosis of CTE was most commonly made through sputum acid-fast bacilli (AFB) smear (n=35, 50%) which most commonly involved right upper (n=20, 28.6%) and lower lung lobes (n=20, 28.6%). Complications such as air leaks, need for ventilator support, need for intensive care unit (ICU) stay, residual collection, and pneumothorax all were significantly higher in Group A (31 patients out of 35) compared to Group B (18 patients out of 35). In Group B, 21 (60%) participants had full post-operative expansion of lungs, compared to eight (22.8%) in Group A (p=0.002). In total five participants had failure to expand lungs; all of them belonged to Group A (p=0.02). CONCLUSION: The optimum timing of surgery and preoperative ATT is crucial for achieving better outcomes and requires good collaboration between the treating pulmonologist and thoracic surgeon. Our study highlights the importance of pre-operative ATT for at least more than six weeks before undertaking decortication for better outcomes and minimizing morbidity.

Morbidity And Mortality Among Patients Sustaining Chest Injury Due To Blunt Force - The Difference Between Young And Elderly.

BACKGROUND: Blunt Chest trauma (BCT) is caused by road traffic accidents (RTAs), falls, assaults, or occupational injuries. Age has been hypothesized to be a predictor of complications and adverse outcomes in the elderly. This study aimed to compare morbidity and mortality in young and elderly patients with BCT. METHODS: This prospective two-arm study was conducted in Jinnah Postgraduate Medical Center, Karachi from July 1st till 31st December 2019 after approval from the Institutional review board. All hemodynamically stable patients with BCT presenting in the emergency were stratified in two groups. Group A included patients age 12-45 years; Group B were of age ≥65 years. Their clinical characteristics, complications, and in-hospital outcomes were compared. Data was analysed using SPSS version 16.0. RESULTS: There were 39 (55.7%) patients in group A and 31 (44.3%) in group B. RTAs were a significant cause of BCT in Group A (p=0.01) and falls in Group B (p=0.003). Lacerations, open wound, and flail chest were significantly more common in Group A (p≤0.05). Complications of BCT including pneumonia and acute respiratory distress syndrome (ARDS) were significantly higher in Group B (p≤0.05). Group B required mechanical ventilation more often (45.2% vs. 12.8%; p=0.003). There were seven deaths in Group B (p=0.002) and none in Group A. CONCLUSIONS: Commonest cause of BCT in the elderly is falling. Similarly, the elderly are more prone to develop pneumonia, ARDS, and the need for ventilatory support. Early intervention to control pain, improve ventilation, and chest physiotherapy reduce the risk of morbidity and mortality.

Rigid Bronchoscopy: A Life-Saving Intervention in the Removal of Foreign Body in Adults at a Busy Tertiary Care Unit.

Introduction Foreign body (FB) aspiration is a potentially lethal emergency and is not uncommon in adults. Rigid bronchoscopy (RB) is a useful procedure for the extraction of these FBs, and it has a high success rate. The aim of this study was to document the clinical presentation of FB aspirations and management outcomes of non-vegetative FB extraction using RB as a therapeutic modality. Method This prospective interventional study was conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi from May 2019 to April 2020. Patients of both genders of ages 12 years or above, presenting with FB aspiration were included. RB was performed in all patients. Results Chest radiograph (CXR) identified FBs in all 60 patients, 51 of whom were females and nine males. In 24 (40%) patients, a CT scan was performed to accurately localize the FB. Left bronchus was the most common location of the FB (n=39; 65%). Scarf pin was the most common type (n=45; 75%) of FB, followed by sewing needle (n=7; 11.7%), safety pin (n=5; 8.3%), and tire repair needle (n=3; 5%). In 53 (88.3%) patients, RB was successful in retrieving the FB. Thoracotomy was performed in the remaining seven patients due to inaccessibility. One (1.7%) patient died due to the rupture of the thoracic aortic aneurysm. Conclusion Accidental aspiration of pins and needles can be fatal in adults. RB is a life-saving modality for safely removing these FBs. However, thoracotomy should be used as a life-saving procedure in cases of FBs affecting secondary bronchi or beyond.

Analysis of Injury Patterns and Outcomes of Blunt Thoracic Trauma in Elderly Patients.

Introduction In the elderly population, trauma is a leading cause of utilization of healthcare, institutionalization, disability, and mortality. In this study, we will assess the injury patterns and the factors associated with the outcomes of blunt thoracic trauma in elderly individuals. Methods This prospective observational study was conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan, from September 2019 to April 2020. The study included patients of both genders aged 60 years and above with blunt thoracic trauma. Patients with concomitant neurological injuries and penetrating trauma to the chest were excluded. Results There were a total of 80 patients in this study; majority were males (n = 66 [82.5%]). The mean age was 70.18 ± 8.3 years. Road traffic accident was the most common mode of injury (n = 45 [56.3%]) followed by fall (n = 32 [40%]). Hemothorax and hemopneumothorax were the most common primary diagnosis. Rib fractures were encountered in 72 (90%) patients. Mortality rate was 21.3% (n = 17). Factors significantly related to mortality were age ≥ 80 years (p = 0.00), tension pneumothorax (p = 0.036), pre-existing cardiopulmonary disease (p = 0.032), blood loss ≥ 500 mL (p = 0.004), flail chest (p = 0.018), and chest trauma score ≥ 5 (p = 0.001). Mean hospital stay in our study was 5.3 ± 3.4 days. Factors lengthening hospital stay by more than five days included lung contusion (p = 0.02), more than two rib fractures (p = 0.004), hemopneumothorax (p = 0.026), pneumonia (p = 0.003), acute respiratory distress syndrome (p = 0.003), and flail chest (p = 0.013). Conclusions Elderly patients with blunt thoracic trauma have higher mortality. Proactive evaluation of injuries using the chest trauma score in the elderly population helps in recognizing patients at high risk of mortality and helps in the timely management to prevent adverse outcomes.

Management Outcome in Simple and Complex Hydatid Cysts of Lung.

INTRODUCTION: Hydatid cyst (HC) of lung is a frequently encountered entity in Pakistan. The clinical and radiological manifestations of HC in lung depend on the integrity of the cyst. Patients may remain asymptomatic for years in cases of simple HC or may present with a wide variety of complications when it ruptures. The aim of this study was to compare management outcomes in simple and complex HCs. METHODS: This prospective, observational study was conducted from February 2019 until May 2020. Patients were divided into two groups: simple HC (Group A) and complex HC (Group B). Preoperative complications, surgical procedures, postoperative complications, duration of hospital stay, duration of chest tube placement and need for readmission were noted and compared between the two groups. All data was processed through the Statistical Package for the Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY). RESULTS: Sixty-two patients were included out of which Group A had 28 (45.2%) patients and Group B had 34 (54.8%) patients. There were 39 (62.9%) males and 23 (37.1%) females. The mean age was 31.11 ± 11.02 years. Preoperative complications in Group B included empyema seen in 10 (28.5%) patients, rupture of cyst into bronchus in 8 (23.5%), biliopleural fistula in 4 (11.7%), hydropneumothorax in 2 (5.8%), bronchopleural fistula in 1 (2.9%), airway compromise in 1 (2.9%) and pneumonia in 1 (2.9%) patient. Group B required longer days of chest tube placement, longer intensive care unit stay and longer hospital stay (p<0.001). The frequency of postoperative intervention was more in group B (p<0.05), therefore requiring readmission. CONCLUSION:  Surgery has favorable outcomes in the management of HC of lung. Complications associated with complex HC not only requires preoperative intervention like chest tubes but can also lead to life-threatening complications. There is also a frequent need for additional procedures during surgery in cases with complex HC along with greater risk of postoperative complications. All these are associated with prolonged hospital stay, readmissions and greater morbidity. Hence, early diagnosis and referral is needed to avoid these preventable complications associated with cyst rupture.

Consequences of traffic noise in residents of Karachi, Pakistan.

OBJECTIVE: To find out effect of road traffic noise on human beings in busy places of Karachi, working at these places and to compare its results with the previously done studies on this subject. METHODS: This prospective epidemiological study was designed to evaluate effects of Noise induced hearing Loss due to road traffic at different places (Gurumander, Tibet Centre, Marry Weather Tower) of Karachi. A sample of 125 cases were randomly selected who had noise exposure of 90 dB or above of their surroundings for more than 6 months. The study was conducted from October 1(st) 2013 to January 1(st) 2013. RESULTS: The minimum age was 18 years while maximum age was 47 years. The age group found most affected was from 23 years to 27 years. The males were 84% and females 16%. Subjects exposed to noise for more than 12 hours per day were 36.8%. Varying degree of hearing loss was evaluated in subjects where 17.6% were normal, 33.6% had mild hearing loss, 45.6% had moderate and 3.2% had moderately severe hearing loss. Traffic noise was found to bother 55.2% of subjects. CONCLUSION: Analysis of data indicates an enormous increase in noise levels as compared to previous studies. This study establishes that there exists a concrete direct link between NIHL and duration of exposure to noise above permissible levels. Traffic authorities should initiate measures to reduce the noise levels in the city particularly at more noisy places.