Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy?

INTRODUCTION/BACKGROUND: Occult pneumothorax (OPTX) is defined as air within the pleural cavity that is undetectable on normal chest X-rays, but identifiable on computed tomography. Currently, consensus is divided between tube thoracostomy and conservative management for OPTX. METHODS: The aim of this retrospective study is to determine whether OPTX can be managed conservatively and whether any adverse events occur under conservative management. Data on all trauma patients from 1 Jan 2010 to 31 December 2012 were obtained from our hospital's trauma registry. All patients with occult pneumothorax who had chest X-ray (CXR) and any CT scan visualizing the thorax were included. The exclusion criteria included those with penetrating wounds; CXR showing pneumothorax, hemothorax, or hemopneumothorax; those with prophylactic chest tube insertion before CT; and those with no CT diagnosis of OPTX. The complications of these patients were analyzed to determine if tube thoracostomy is necessary for OPTX and whether not inserting it would alter the outcome significantly. RESULTS: A total of 1564 cases were reviewed and 83 patients were included. Of these 83 patients, 35 (42.2 %) had tube thoracostomy after OPTX detection and 48 (57.8 %) were observed initially. Patients who had tube thoracostomy had similar ISS compared to those without (median ISS 17 vs. 18.5, p = 0.436). Out of the 48 patients who did not have tube thoracostomy on detection of an OPTX, 4 (8.3 %) had complications. In the group of 35 patients who had tube thoracostomy on detection of an OPTX, 7 (20 %) had complications. Of the 83 patients, a total of 12 patients had IPPV, of which 7 (58.3 %) had tube thoracostomy and 5 (41.7 %) did not. Patients who had tube thoracostomy under our care have a statistically significant likelihood of experiencing any complication compared to those without tube thoracostomy (odds ratio 9.92. The median length of stay was also longer (13 days) in those who had tube thoracostomy compared to those without (5 days) (p value = 0.008). CONCLUSIONS: Our study suggests that patients with OPTX can be managed conservatively with close monitoring, but only in areas with ready access to emergency facilities should any adverse events occur.

Emergency angio-embolisation in the operating theatre for trauma patients using the C-Arm digital subtraction angiography.

BACKGROUND AND AIMS: Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control. METHODS: A retrospective study of trauma patients, with Injury Severity Score (ISS ≥ 9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts. RESULTS: A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n = 32). None of the patients who received angioembolisation in the operating theatre (n = 32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures. CONCLUSION: The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.

Structural studies on the biosides of Digitalis lanata: bisdigitoxosides of digitoxigenin, gitoxigenin and digoxigenin.

The crystal structures and conformations of bisdigitoxosides of digitoxigenin (I), gitoxigenin (II) and digoxigenin (III and IV) have been determined using single-crystal X-ray crystallographic techniques. Crystals of (I), (II) and (IV) were grown from ethyl acetate solutions of the glycosides while (III) was grown from a solution of the digitoxoside in ethanol. As in other cardiac glycosides the ring junctions A-B and C-D are cis. The D ring in these structures shows different conformations while the A, B and C rings remain conformationally similar. Although digitoxigenin bisdigitoxoside and gitoxigenin bisdigitoxoside differ from each other in the absence and presence of a hydroxyl group at C(16) of the D ring, these two biosides crystallize in the space group P2(1)2(1)2 [corrected] and are isomorphous. The presence of the hydroxyl group at C(16) does not affect the orientation of the lactone ring and the conformation of the molecule. Digoxigenin bisdigitoxoside crystallizes in two different crystal systems with four molecules of water in the orthorhombic form and one molecule of ethyl acetate in the triclinic form. In both forms the hydroxyl at C(3') of the first sugar forms a hydrogen bond with the ring oxygen of the second sugar. This has also been observed in the trioside digoxin. The torsion angle C(13)-C(17)-C(20)-C(22) in the two forms differs by 7 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)