Surgical removal of an impaled unexploded mortar shell into the chest: Case review from a war-zone.

INTRODUCTION AND SIGNIFICANCE: The surgical removal of unexploded mortar shells is rarely documented in the literature. Since most cases occur within war or conflict regions, reporting such instances is vital for optimizing and enhancing surgical practices, particularly in low-resource settings. CASE PRESENTATION: We report the case of a 35-year-old man who sustained an injury from a 60 mm unexploded mortar shell, penetrating the patient's right posterior chest in the right paravertebral region of the 4th thoracic vertebra, causing intrathoracic injuries, multiple rib fractures, and a right pneumothorax. The patient was immediately resuscitated and transferred to the operating room. The projectile was removed without direct contact with metal instruments. A right chest tube was then inserted and the injured area was repaired, resulting in an uneventful postoperative recovery. CLINICAL DISCUSSION: Unexploded mortar shell injuries are infrequently documented in the literature. These injuries are seen within war and conflict regions, that have limited accessibility or availability of experienced explosive ordnance disposal (EOD) teams, transporting personnel, and equipped and separated operating theaters. CONCLUSION: Unexploded ordnance and munitions represent an underrecognized and underreported health risk to patients, healthcare providers, and healthcare facilities. These injuries are commonly encountered within regions that lack experienced transport and EOD staff. The need for the establishment of such experienced teams along with providing adequate training for healthcare providers is necessary.

Closed Thoracic Trauma as an Exceptional Cause of Pneumorrhachis: A Case Report.

Pneumorrhachis, a rare clinical entity, refers to the presence of air in the spinal canal. Air can enter the spinal canal through various pathways, including the lungs and mediastinum (the space between the lungs), or directly from external sources due to trauma or infection. In rare cases, pneumorrhachis may result from repeated secondary Valsalva maneuvers, which is a complication of large-area pneumothorax. In this case report, we discuss a 36-year-old male patient who was involved in a high-intensity road accident. The injury assessment revealed significant findings including a large left pneumothorax, a right pneumothorax, multiple rib fractures, and the presence of pneumorrhachis. The entry of air into the spinal canal originated from the pleural space, likely through injuries to the parietal pleura. Rarely reported, closed thoracic trauma is an exceptional cause of pneumorrhachis. This unique mechanism of injury has been described in a limited number of publications addressing traumatic pneumorrhachis. The identification of pneumorrhachis in a traumatized patient should prompt further investigation to explore other potential injuries that may elucidate the formation of this intraspinal gas collection.

Evaluating the Shock Index, Revised Assessment of Bleeding and Transfusion (RABT), Assessment of Blood Consumption (ABC) and novel PTTrauma score to predict critical transfusion threshold (CAT) in penetrating thoracic trauma.

The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.

Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study.

INTRODUCTION: Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults. AIMS: i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma. METHODS: A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019. RESULTS: After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days. CONCLUSION: Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Study of risk factors for injuries due to cardiopulmonary resuscitation with special focus on the role of the heart: A machine learning analysis of a prospective registry with multiple sources of information (ReCaPTa Study).

Background: The study of thoracic injuries and biomechanics during CPR requires detailed studies that are very scarce. The role of the heart in CPR biomechanics has not been determined. This study aimed to determine the risk factors importance for serious ribcage damage due to CPR. Methods: Data were collected from a prospective registry of out-of-hospital cardiac arrest between April 2014 and April 2017. This study included consecutive out-of-hospital CPR attempts undergoing an autopsy study focused on CPR injuries. Cardiac mass ratio was defined as the ratio of real to expected heart mass. Pearson's correlation coefficient was used to select clinically relevant variables and subsequently classification tree models were built. The Gini index was used to determine the importance of the associated serious ribcage damage factors. The LUCAS® chest compressions device forces and the cardiac mass were analyzed by linear regression. Results: Two hundred CPR attempts were included (133 manual CPR and 67 mechanical CPR). The mean age of the sample was 60.4 ± 13.5, and 56 (28%) were women. In all, 65.0% of the patients presented serious ribcage damage. From the classification tree build with the clinically relevant variables, age (0.44), cardiac mass ratio (0.26), CPR time (0.22), and mechanical CPR (0.07), in that order, were the most influential factors on serious ribcage damage. The chest compression forces were greater in subjects with higher cardiac mass. Conclusions: The heart plays a key role in CPR biomechanics being cardiac mass ratio the second most important risk factor for CPR injuries.

Minimally invasive management of thoracic trauma: current evidence and guidelines.

Minimally invasive procedures are being increasingly proposed for trauma. Injuries to the chest wall and/or lung have historically been managed by drainage with a large bore thoracostomy tube, while cardiac injuries have mandated sternotomy. These treatments are associated with significant patient discomfort. Percutaneous placement of small 'pigtail' catheters was initially designed for drainage of simple pericardial fluid. Their use subsequently expanded to drainage of the pleural cavity. The role of pigtail catheters for primary treatment of traumatic pneumothorax and hemopneumothorax has increased, while their use for pericardial fluid after trauma remains controversial. Pericardial windows have alternatively been purposed as a minimally invasive treatment option for possible hemopericardium. The aim of this article is to review the current evidence and guidelines for minimally invasive management of chest trauma.

Pneumothorax Secondary to a Traumatic Brazilian Jiu-Jitsu Injury.

A pneumothorax is a medical condition characterized by the presence of free air in the pleural cavity. Pneumothorax can be classified as spontaneous, traumatic, or iatrogenic. Spontaneous pneumothorax sustained from a jiu-jitsu-induced blunt trauma has not been described in any sports literature. This case report involves a 26-year-old male athlete who presented to the emergency room complaining of right-sided chest pain in the recumbent position and shortness of breath upon exertion. Breath sounds were diminished on the right with hyper resonance to percussion. Inspection of the chest revealed diffuse erythema on the right side. A chest X-ray revealed a right tension pneumothorax that was treated with a 20-French chest tube. This report aims to highlight the importance of recognizing the possibility of pneumothorax in jiu-jitsu athletes, implementing early treatment, and exploring potential causes of pneumothorax in otherwise healthy individuals.

Surgical Rib Fracture Fixation: Early Operative Intervention Improves Outcomes.

Background: This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or nonoperative management at our major trauma center. Methods: A retrospective review of all patients who were considered for surgical stabilization of rib fractures (SSRF) at a single major trauma center from May 2016 to September 2022 was performed. Results: In total, 352 patients with complex rib fractures were identified. Thirty-seven patients (11%) fulfilled the criteria for surgical management and underwent SSRF. The SSRF group had a significantly higher proportion of patients with flail chest (32 [86%] vs. 94 [27%], p<0.001) or Injury Severity Score (ISS) >15 (37 [100%] vs. 129 [41%], p<0.001). No significant differences were seen between groups for 1-year mortality. Patients who underwent SSRF within 72 hours were 6 times less likely to develop pneumonia than those in whom SSRF was delayed for over 72 hours (2 [18%] vs. 15 [58%]; odds ratio, 0.163; 95% confidence interval, 0.029-0.909; p=0.036). Prompt SSRF showed non-significant associations with shorter intensive care unit length of stay (6 days vs. 10 days, p=0.140) and duration of mechanical ventilation (5 days vs. 8 days, p=0.177). SSRF was associated with a longer hospital length of stay compared to nonoperative patients with flail chest and/or ISS >15 (19 days vs. 13 days, p=0.012), whilst SSRF within 72 hours was not. Conclusion: Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Delayed surgical fixation was associated with increased rates of pneumonia and a longer hospital length of stay.

Algoritmo diagnóstico y terapéutico de las lesiones esplácnicas provocadas durante la inserción de sondas pleurales / Diagnostic and Therapeutic Algorithm for Splanchnic Injuries Caused during Chest Tube Insertions

Introducción: La colocación de sondas pleurales es un procedimiento quirúrgico frecuente que puede tener graves complicaciones, las cuales dependen en la mayoría de los casos de la experiencia del operador, el tamaño del tubo y el uso de imágenes para guiar la inserción. Objetivo: Describir las principales lesiones esplácnicas provocadas durante la inserción de sondas pleurales y presentar algoritmos para el diagnóstico precoz y el tratamiento oportuno de estas iatrogenias. Métodos: Se realizó una revisión descriptiva narrativa durante el primer trimestre del año 2023. Se utilizaron las bases de datos electrónicas PubMed, LILACS, EBSCO y Cochrane. Se revisaron artículos publicados desde 1984 hasta el 2022. Se procuró que la mayoría de la información se enmarcara en un período no mayor de 10 años de antigüedad. Desarrollo: De las lesiones esplácnicas de la cavidad torácica, la de pulmón es la más frecuente y puede conducir a sangrado o fuga aérea persistente. Las lesiones vasculares son graves y pueden provocar la muerte si no se toman las medidas pertinentes. Se han descrito lesiones de órganos huecos de la cavidad abdominal que suelen ser parte de una hernia diafragmática. Dentro de las lesiones esplácnicas en el abdomen más frecuentes están la hepática y la esplénica. Conclusiones: Estas lesiones son prevenibles y se debe tener en cuenta su mecanismo de producción para evitarlas. Para este fin recomendamos una selección cuidadosa del sitio de inserción, realizar una confirmación adecuada de la posición de la sonda, manipularla cuidadosamente y monitorear constantemente al paciente(AU)

Introduction: Chest tube insertion is a frequent surgical procedure that can have serious complications, which depend mostly on the practitioner's experience, the tube's size and the use of imaging to guide the insertion. Objective: To describe the main splanchnic injuries caused during chest tube insertion, as well as to present algorithms for early diagnosis and timely treatment of these types of iatrogeny. Methods: A descriptive narrative review was performed during the first quarter of the year 2023. The electronic databases PubMed, LILACS, EBSCO and Cochrane were used. Articles published from 1984 to 2022 were reviewed. Most of the information was secured to be framed within a period of no more than 10 years. Development: Among the splanchnic injuries within the thoracic cavity, lung injury is the most frequent and may lead to bleeding or persistent air leak. Vascular injuries are severe and can lead to death if appropriate measures are not taken. Injuries to hollow organs of the abdominal cavity have been described to be usually part of a diaphragmatic hernia. Among the most frequent splanchnic lesions within the abdomen are the hepatic and splenic injuries. Conclusions: These lesions are preventable and their mechanism of production should be taken into account in order to avoid them. To achieve this, we recommend that the insertion site be carefully selected and that the tube's position be adequately confirmed, as well as the careful handling of the tube and the constant monitoring of the patient(AU)

Penetrating chest injury secondary to an improvised home-made marble airgun: a case report.

Background: An improvised air gun with marble bullets, locally known as "Jolen Gun", is a type of home-made gun using Polyvinyl chloride (PVC) pipes and compressed air. It is mainly being used as a hunting tool in Central Mindanao. This "non-lethal" weapon has the potential in causing serious harm. There has been several incidents of minor injuries from this type of weapon in our institution but this is the first documented case of an improvised marble air-gun causing significant injury to the patient. Case report: A child was brought to a rural tertiary center after being shot in the chest using an improvised gun with marble as bullet. On evaluation, the patient had a single gunshot wound approximately 2cm x 2cm in size on the posterior chest at the right paravertebral area of the 4th thoracic vertebra. There was no exit wound noted. Chest CT done showed a rounded radiopaque foreign body seen in the right upper lung field with gunshot fracture involving the posterior aspect of the 4th rib. There was also pulmonary contusion of the right upper lobe and a fluid density at the right posterior pleural space attributed to a hemothorax. Open thoracotomy, removal of foreign body, repair of lung injury and debridement was done. Patient had an unremarkable post-operative course and was subsequently discharged. Conclusion: After extensive search of both local and international literatures, this appears to be the first case involving a penetrating chest injury from an improvised marble air-gun which has been treated successfully. Although this is a low-energy type of weapon, it still has the potential to cause significant harm to the body. Relevant laws should be made to against the use of this type of weapon to prevent similar injuries in the future.

Intrathoracic plates versus extrathoracic plates: a comparison of postoperative pain in surgical stabilization of rib fracture technique.

Background: Surgical stabilization of rib fractures (SSRF) has been shown to improve outcomes, yet there is an absence of studies comparing SSRF techniques. An intrathoracic system that minimizes incision length has recently been developed and adopted by multiple institutions. We hypothesized that SSRF with an intrathoracic system plus intercostal nerve cryoneurolysis (IC) leads to improved pain control compared with an extrathoracic system plus IC. Methods: A single-center, retrospective chart review was performed comparing intrathoracic SSRF versus extrathoracic SSRF, and included patients undergoing SSRF from 2015 to 2021 at a level 1 trauma center. Patients who did not undergo intercostal nerve cryoablation were excluded. The primary outcome was opioid consumption based on morphine milligram equivalent (MME) consumption. We collected Rib score, Blunt Pulmonary Contusion 18 Score, number of rib fractures, number of ribs plated, and Injury Severity Score (ISS) to compare baseline characteristics of each group. Results: A total of 112 patients were evaluated for study inclusion. Thirty-one patients were excluded due to missing outcomes data and/or lack of cryoablation. There was no difference in ISS or Rib Score between the intrathoracic (n=33) and extrathoracic (n=48) groups. At 7-day follow-up, the median MME requirement was significantly lower in the intrathoracic group (21.25) versus the extrathoracic group (46.20) (p=0.02). Conclusion: Intrathoracic SSRF was associated with a lower postoperative MME consumption compared with extrathoracic SSRF. These data support the use of intrathoracic SSRF to improve pain control compared to extrathoracic SSRF. Level of evidence: III.

Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study.

BACKGROUND: Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population. METHODS: Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed. RESULTS: The study included 177 patients with chest trauma and pulmonary contusion on CT scan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01). CONCLUSIONS: Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials.

PURPOSE: Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. METHODS: Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. RESULTS: Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. CONCLUSIONS: Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

A Knife Penetrating the Right Ventricle, Interventricular Septum, and 2 Valves: A Case Report.

Penetrating chest trauma may result in significant intracardiac injury. A traumatic ventricular septal defect is a rare complication that requires surgical management, particularly if heart failure ensues. We report a case of delayed repair of an outlet-type ventricular septal defect and perforation of the aortic and pulmonary valve leaflets following a stab wound. This report highlights diagnostic and surgical considerations and also presents an opportunity to review the conotruncal anatomy, which may be relatively unfamiliar to many adult cardiac surgeons.

Brief report on the development of hemorrhagic pericardial effusion after thoracic surgery for traumatic injuries.

Introduction: Hemorrhagic pericardial effusion (HPE) is a rare but life-threatening diagnosis that may occur after thoracic trauma. Previous reports have concentrated on delayed HPE in those who did not require initial surgical intervention for their traumatic injuries. In this report, we identify and characterize the phenomenon of HPE after emergent thoracic surgery for trauma. Methods: This is a retrospective review of patients who required emergent thoracic surgery for trauma at a level 1 trauma center from 2017 to 2021. Using the institutional trauma database, demographics, injury characteristics, and outcomes were compared between patients with HPE and those without HPE after thoracic surgery for trauma. Results: Ninety-one patients were identified who underwent emergent thoracic surgery for trauma. Most were young men who sustained a penetrating thoracic injury. Seven patients (7.7%) went on to develop HPE. Patients who developed HPE were younger (18 vs. 32 years, p=0.034), required bilateral anterolateral thoracotomy (85% vs. 7%, p<0.001), and were more likely to have pulmonary injuries (100% vs. 52.4%, p<0.001). Five patients with HPE survived to hospital discharge. The two patients with HPE who died were both coagulopathic and had HPE diagnosed within 4 days of injury. The median time to HPE diagnosis in survivors was 24 days with four of five HPE survivors on therapeutic anticoagulation at the time of diagnosis. Conclusions: HPE may occur after emergent thoracic surgery for trauma. Those at highest risk of HPE include younger patients with bilateral thoracotomy incisions and pulmonary injuries. Early HPE, clinical signs of tamponade, and/or coagulopathy in patients with HPE portend a worse prognosis. Surgeons and trauma team members caring for patients after emergent thoracic exploration for trauma should be aware of this potentially devastating complication and should consider postoperative echocardiography in high-risk patients.

Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions.

OBJECTIVE: This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database. METHODS: This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group. RESULTS: The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk. CONCLUSIONS: The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

Accidental gunshot injury with left-sided lung injury and D11 burst fracture: a case report.

Penetrating chest injuries are mainly caused by gunshot trauma and stab injuries. These lead to damage to the vital structures, which requires a multidisciplinary approach for management. Case presentation: We present a case of an accidental gunshot injury (GSI) to the chest resulting in left-sided hemopneumothorax, left lung contusion, and D11 burst fracture with spinal cord injury. The patient underwent thoracotomy to remove the bullet along with instrumentation and fixation of the D11 burst fracture. Clinical discussion: Penetrating trauma to the chest requires prompt resuscitation and stabilization with eventual definitive care. Most GSIs to the chest require chest tube insertion, which helps to create negative pressure in the chest cavity, allowing adequate time for the expansion of the lungs. Conclusion: GSIs to the chest could give rise to life-threatening conditions. However, the patient must be stabilized for at least 48 h before performing any surgical repair to ensure that there are fewer complications following surgery.