This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
BACKGROUND: Penetrating cardiac injuries in Europe have been poorly studied. We present a 10-year outcome for patients with penetrating heart injuries at Oslo University Hospital. METHODS: Data from 01.01.2001 until 31.12.2010 was collected from the Oslo University Hospital Trauma Registry and from the patients' records. RESULTS: Thirty-one patients were admitted with a penetrating cardiac injury. Fourteen patients survived (45%). Four out of 8 patients (50%) with gunshot wounds survived compared to 10 out of 23 (44%) with stab wounds. Median (quartiles) for the following values were: Injury Severity Score 25 (21-35), Revised Trauma Score 0 (0-6,9), Probability of Survival 0,015 (0,004-0,956), Glasgow Coma Scale 3 (3-13). Thirteen patients had signs of life on admission and survived. Eighteen patients were admitted without signs of life and received emergency department thoracotomy. Eight of these had no signs of life at the scene of injury and did not survive. Out of the remaining 10 patients, one survived. CONCLUSIONS: The outcome of patients with penetrating cardiac injury reaching the emergency department with signs of life was excellent. Hemodynamic instability indicates immediate surgery. Stable patients with penetrating thoracic trauma and possible cardiac injury detected by imaging should be considered for conservative treatment.
Tracheobronchial injury is one of cases which are relatively uncommon, but must be suspected to make the diagnosis and managed immediately. In such a case, primary initial goals are to stabilize the airway and localize the injury and then determine its extend. These can be possible mostly with flexible bronchoscopy conducted by a surgeon who can repair the injury. Most of the penetrating injuries occur in the cervical region. On the other hand, most of the blunt injuries occur in the distal trachea and right main bronchus and they can be best approached by right posterolateral thoracotomy. The selection of the manner and time of approaching depends on the existence and severity of additional injuries. Most of the injuries can be restored by deploying simple techniques such as individual sutures, while some of them requires complex reconstruction techniques. Apart from paying attention to the pulmonary toilet, follow-up is crucial for determination of anastomotic technique or stenosis. Conservative treatment may be considered an option with a high probability of success in patients meeting the criteria, especially in patients with iatrogenic tracheobronchial injury.
Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.