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   Table of Contents - Current issue
January-December 2021
Volume 6 | Issue 1
Page Nos. 1-36

Online since Wednesday, December 22, 2021

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Usual and unusual intrathoracic hemorrhage p. 1
Kenneth L Mattox
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A contemporary algorithm to manage acute rib fractures in the intensive care unit p. 4
John Alfred Carr
Operative stabilization of both flail and nonflail rib fractures has become very common, with a 76% increase in community hospitals over the past 10 years. This review will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the intensive care unit (ICU) setting with rib fractures. A PubMed and Medline literature search was conducted with the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, and ribs. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, cohort studies, and reviews. Selected publications of interest on both rib plating and conservative treatment were retrieved and their bibliographies were also reviewed to identify relevant publications. Data from the relevant publications were reviewed, summarized, and the information synthesized. Rib plating has shown improved outcomes in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU and hospital stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows the physician to easily determine which patients are appropriate for rib plating.
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Thoracic duct injury: An up to date p. 15
Josť Luis Ruiz Pier, Moheb A Rashid
Trauma represents a significant portion of the world's morbidity and mortality. Chest trauma accounts for approximately 25% of mortality in trauma patients, and this rate is much higher in patients with polytraumatic injuries. The thoracic cavity contains three major anatomical systems: the airway, lungs, and the cardiovascular system including the thoracic duct. Blunt or penetrating trauma can cause significant disruption to each of these systems that can quickly prove to be life threatening unless rapidly identified and treated. In the present article, the authors present a review of the thoracic duct injury evaluation and treatment.
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Which comorbidities matter most in patients with multiple rib fractures? An analysis of the national inpatient sample p. 22
Christopher W Towe, Avanti Badrinathan, Vanessa P Ho, Katelynn C Bachman, Stephanie G Worrell, Matthew L Moorman, Philip A Linden, Fredric M Pieracci
Background: Increased age and number of rib fractures are known to increase the risk of mortality. The impact of comorbidities on the outcomes of patients with rib fractures has not previously been described. We hypothesized that specific medical comorbidities are associated with increased risk of morbidity and mortality following rib fracture. Methods: Patients with multiple rib fractures or flail chest were identified in the National Inpatient Sample by ICD-10 code from the 4th quarter of 2015 through 2016. Comorbidities were categorized into Elixhauser comorbidity groups, and injury severity was estimated using the Injury Severity Score (ISS). The composite adverse outcome was defined as death, pneumonia, tracheostomy, or discharge to a short-term acute care facility. Multivariable logistic regression was performed with covariates chosen through backward selection from the univariate model to determine the relationship of outcomes to demographic variables and comorbidities with alpha set to 0.001. Results: Totally 26,289 patients met inclusion criteria. Composite adverse outcomes occurred in 5,132 (19.5%) patients. Profound ISS (OR 6.013), severe ISS (odds ratio [OR] 2.569), fluid and electrolyte disorder (OR 2.471), and paralysis (OR 2.372) were most associated with adverse outcomes. Within causes of injury, motor vehicle was associated with increased risk of adverse outcome (OR 1.322). Flail chest was also independently associated with adverse outcome (OR 1.816). Conclusion: Morbidity and mortality following rib fracture occurred in approximately one-fifth of patients, especially those with high ISS or associated medical comorbidities. This data can be used for risk stratification and identification of high-risk patients for escalation of care.
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Intraoperative evaluation by ultrasound of multiple rib fractures in trauma patients p. 28
Gustavo Cruz, Alvaro I Sanchez, Juan Carlos Puyana, Mauricio Velasquez
Introduction: Increased interests in surgical approaches for multiple rib fractures in trauma patients have emerged lately. A novel strategy based on intraoperative ultrasound (US) assessment to locate these fractures has been proposed to perform smaller incisions for thoracic wall reconstructions. We aimed to describe variations of site, size, and direction of surgical incisions before and after US use intraoperatively for localization of rib fractures. Materials and Methods: In this pilot study, ten trauma patients with multiple rib fractures requiring thoracic wall reconstruction were prospectively included during a 9-month period. Computer tomography of the thorax was used for determining surgical incisions. Before surgical incision, US was used for the identification of rib fractures and for marking a different surgical incision. In each patient, qualitative comparisons of surgical incision marks before and after US were performed. Results: The qualitative analysis demonstrated that five patients (5/10) had a change in the direction of the incision and also in five patients (5/10) there was a change in the size of the incision. In those five patients in whom the length and size of the incision changed, there was a median length reduction of the incision of 3 cm (interquartile range 2–3). Conclusions: In this pilot study, we observed that trauma patients with multiple rib fractures requiring thoracic wall reconstruction may benefit from intraoperative assessment of US for targeted surgical planning. US might offer advantages for surgical planning before defining the final surgical approach.
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Impalement injury to chest due to bamboo stick p. 32
Majid Anwer, Md Masleh Uddin, Farheen Ahmed, Md Atique Ur Rahman
Impalement injuries are rare. We present here a case of impalement injury of chest and its management. A 10-year-old boy fell from a tree and landed on pointed bamboo object. He was diagnosed as a case of impalement injury with right-sided pneumothorax. A right anterolateral thoracotomy with removal of foreign body and repair of lung laceration was done. The patient in the postoperative period remained stable. He was discharged on day 10. Thoracic impalement injuries are dangerous injuries because of close proximity of the impaled objects to the heart and major vessel. The impaled object should be left as such and an urgent transfer to a facility dealing with such type of injury is required. A thoracotomy incision based on the tract should be employed. Postoperative patient should be put on broad-spectrum antibiotic along with chest physiotherapy.
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Chest tube perforating spleen and liver p. 35
Moheb A Rashid
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Emergency resuscitative thoracotomy for traumatic hemorrhagic shock p. 36
Moheb A Rashid
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