ABSTRACT
INTRODUCTION AND IMPORTANCE: Lung herniation following trauma is a rare occurrence, and consensus on optimal surgical repair techniques remains limited. While small herniations may resolve without surgery, intervention becomes necessary in cases of unsuccessful non-operative management or concurrent rib fracture stabilization. Mesh application in repair poses a dilemma, often providing physical support but raising infection concerns, particularly in trauma scenarios with delayed closure. Surgical stabilization of rib fractures, employing hardware similar to orthopedic procedures, may necessitate prophylactic antibiotics, though empirical evidence supporting routine use is scant. Polytrauma patients often resort to delayed chest closure techniques during methodical surgical planning, but these carry potential consequences compared to immediate closure. CASE PRESENTATION: Presented is a case involving a patient in a motorcycle collision sustaining multiple injuries, necessitating a massive transfusion protocol, multiple surgeries, including delayed chest closure, and eventual surgical rib fixation four days post-injury. During rib stabilization, exacerbation of traumatic lung herniation mandated mesh repair, prompting the cautious use of prophylactic vancomycin powder to mitigate infection risks. DISCUSSION: A review of the literature revealed a scarcity of similar cases, particularly those involving lung herniation with delayed chest closure, the use of prophylactic antibiotics and mesh in polytrauma. CONCLUSION: This case underscores the lack of depth of comprehensive research guiding surgical decisions concerning lung herniation and the prophylactic use of vancomycin powder in trauma patients.
ABSTRACT
BACKGROUND: Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS: This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS: There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04). CONCLUSION: Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level III.
