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Chest trauma: “Damage Control” Begins in the emergency room
Bradley J Phillips, Lauren Turco
January-December 2017, 2(1):3-9
Background: Patients with severe thoracic injuries and subsequent physiological decline may not be candidates for initial definitive treatment. Despite limited data, this subset of patients may benefit from the implementation of thoracic damage control, which should begin in the emergency room. Methods: A literature search was conducted through Medline following PRISMA guidelines. Articles that focused on damage control surgery, the use of damage control techniques in traumatic injuries, and the use of damage control in civilian populations were selected. Due to the paucity of literature and lack of Level I evidence on this subject, studies published in any year were considered. Results: A search of the literature yielded 119 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were selected for review. The majority of these were classified as Level III, IV, or V evidence. Limitations: Limitations of this article are similar to all PRISMA-guided review articles: The dependence on previously published research and availability of references. Conclusion: Effective “Damage Control” following a traumatic injury begins with initial management in the emergency department, which is followed by an abbreviated operation, equally aggressive critical care, and a planned reexploration. Additional studies are required to examine the adaptation of specific damage control techniques to thoracic injuries, but patients with severe chest trauma can benefit from initiation of damage control strategies in the emergency room.
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Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance
Moheb A Rashid, Mohammad A Rashid
July-December 2016, 1(1):4-7
Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.
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Silent Cardiac Wound
Bruno José da Costa Medeiros
July-December 2016, 1(1):19-20
A 27-year-old male had a stab wound on the anterior chest. The patient was hemodynamically stable. Vital signs were normal in the beginning. Breath and cardiac sounds were normal. Chest X-ray revealed no signs of hemothorax or pneumothorax. Focused Assessment Sonography for Trauma (FAST) was negative. Reevaluated after 2 h, he continued apparently stable, and only his blood pressure was a little lower 100 × 60 mmHg. Second FAST was positive. He had a punctate ventricular lesion, corrected with horizontal suture. We reinforce the importance of reevaluation of the patient and systematically do the FAST or pericardial window in patients with suspected cardiac lesion.
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Chest Tube Insertion: A Safe and Simple Technique
Moheb A Rashid
July-December 2016, 1(1):12-12
  4,123 0 -
The First International Congress of the World Society for Cardiothoracic Trauma: Lessons learned
Moheb A Rashid
January-December 2018, 3(1):1-2
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Necessity is the mother of invention: Rib fixation with pediatric ankle plates and screws after successful thoracoabdominal damage control surgery
Moheb A Rashid
January-December 2019, 4(1):1-2
  3,784 1 -
The emerging educational power of the journal of cardiothoracic trauma: Highlights of direct lethal injuries
Moheb A Rashid
January-December 2017, 2(1):1-2
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Controversies in cardiac trauma
Kenneth L Mattox
January-December 2018, 3(1):3-4
  3,583 5 -
Cardiac and Thoracic Effects Following Trauma: Foreword with Perspective and Philosophical Reflections
Kenneth L Mattox
July-December 2016, 1(1):1-2
  3,457 2 -
Blunt thoracic aortic injury
Tara Talaie, Jonathan J Morrison, James V O’Connor
January-December 2018, 3(1):11-18
Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.
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Intercostal pericardial window: A Safe, expedient, and effective minimally invasive technique
Moheb A Rashid, Fredrik Holmner
January-December 2017, 2(1):21-22
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Damage Control Thoracic Surgery
James V O'Connor
July-December 2016, 1(1):8-11
Damage control as a management strategy for the most severely injured and metabolically depleted patients was first utilized for penetrating abdominal trauma. The principles are early hemorrhage control, limiting enteric contamination, resuscitation in the intensive care unit and, a delayed, definitive re-operation when normal physiology is restored. Since its initial use over two decades ago, the principles of damage control have been successfully utilized in the management of vascular and orthopedic injuries, and more recently in volume resuscitation. There has been a slower adoption of damage control approach to thoracic trauma, primarily due to concerns of cardiac tamponade and impaired pulmonary physiology, both the result of packing the pleural space. This review article describes philosophy, techniques and outcomes of damage control thoracic surgery.
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Late cardiac tamponade after cardiac trauma: A case report and a review
Bruno Jose da Costa Medeiros, Hugo Marlon de Castro Negreiros, Luiz da Gama Pessoa
January-December 2017, 2(1):10-13
The pericarditis is an inflammation process of the pericardium with lots of causes, primary and secondary. It may progress with pericardial effusion and/or constrictive pericarditis. The presentation as late cardiac tamponade due to trauma is a rare clinical condition and may occur days or weeks after trauma. We report a case observed in a trauma hospital of Manaus-Amazonas, Brazil periphery. The patient presented to the hospital 18 days after a chest trauma with signs and symptoms of cardiac tamponade: tachycardia, turgid jugular veins, inferior limbs swollen, presenting breathing difficulties, and supine position not tolerated. He underwent exploratory thoracotomy, and a thick pericardium with purulent effusion was found. It is important to suspect cadiac injury in patients who are victims of trauma on cardiac box, to observe that the focused assessment sonography for trauma is used, but it has its limitations. It is 90%–95% accurate for the presence of pericardial fluid for the experienced operator. Concomitant hemothorax may account for both false-positive and false-negative ultrasound examinations.[2] When necessary, the subxiphoid exploration must be done. The possibility of occult cardiac lesion or silent cardiac wound should always be considered in patients with chest trauma by knife or gunshot on Zieddler area or cardiac box, to prevent a late cardiac tamponade or pericarditis.
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Unique Journal of A New World Society
Demetrios Demetriades
July-December 2016, 1(1):3-3
  2,940 1 -
Cardiac Tamponade from Isolated Right Atrial Rupture: A Rare Presentation of Blunt Chest Trauma Without Rib Fracture
Ganesh Kumar K Ammannaya, Chaitanya Raut, Chandan Kumar Ray Mohapatra, Harsh Seth
July-December 2016, 1(1):13-15
Cardiac tamponade resulting from blunt chest trauma is an emergent and life-threatening condition. Cardiac rupture from blunt chest trauma is not a common presentation, and more so in the absence of rib or sternal fracture. We present a case of blunt chest trauma, who presented with features of cardiac tamponade. Emergency sternotomy revealed a right atrial rupture near the appendage which was surgically repaired. The patient also underwent simultaneous splenectomy for Grade 4 splenic injury. The patient recovered uneventfully. Prompt recognition of the injury based on a high index of suspicion must lead to immediate surgical intervention in order for these patients to survive, even in the absence of specialized imaging investigations.
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A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures
Helen Ingoe, Catriona Mcdaid, William Eardley, Amar Rangan, Catherine Hewitt
January-December 2018, 3(1):5-10
Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.
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Tension Pneumomediastinum in a Patient with H1N1 Pneumonia: A Rare Case Report
Chenna Keshava, Sreekar Balasundaram, Maria Denzil
July-December 2016, 1(1):16-18
We report here the case of a 28-year-old pregnant woman who developed adult respiratory distress syndrome, ventilator-associated injury, and sepsis following H1N1 virus infection. She presented with rapidly worsening breathlessness and a 4-day history of fever. Initial computed tomography scan of the chest showed right mid and lower zone alveolar infiltrates. Immediate postadmission, she was tachypneic and required high concentration oxygen to maintain saturations. The patient recovered following prolonged ventilator support, moderate inotrope support, and 6 weeks of hospital stay. The study highlights the significance of prompt diagnosis and management of tension pneumomediastinum to prevent any life-threatening complications.
  2,557 0 -
Complex cardiac stab wound
Bruno José da Costa Medeiros, Ricardo Silva de Morais
January-December 2017, 2(1):17-20
A 50-year-old male come to the hospital victim of damage with a knife to anterior chest (precordial region) after a fight 1 h before. Cardiac tamponade was discovered by focused assessment sonography for trauma and was positive with fluid in pericardial sac. The patient was taken to the operating room. A left anterior thoracotomy was performed. There were three cardiac lesions: One was on the right ventricle, another was very near the left coronary artery (descending anterior branch), and the last one was on pulmonary artery trunk. All the three lesions were corrected with horizontal sutures with prolene 3-0, the lesion near the coronary artery was corrected with a horizontal suture under the artery. Complex cardiac wound is always a challenger to the surgeon, in this case, a cardiac lesion was so near the left coronary artery, a suture over the artery could lead to a myocardial infarction and even death of the patient.
  2,327 20 -
Traumatic tension pneumopericardium: A rare complication
P Vivekananthan, Mudalipalayam N Sivakumar, Mohamed Hisham, S Lakshmikanthcharan
January-December 2017, 2(1):14-16
A 36- year old male was admitted with shock following a road traffic accident. The patient had a low Glasgow Coma Scale score of 8/15 for which he was ventilated and intubated. Computed tomography scan showed pneumomediastinum and pneumopericardium along with left-sided hemopneumothorax. Hemopneumothorax was addressed with an intercostal drain. There was no further blood loss. Persisting hemodynamic compromise needing inotropic support prompted a diagnosis of tamponading effect of pneumopericardium. Pericardiocentesis was performed which resulted in immediate hemodynamic stability. The patient was discharged from intensive care unit after tracheostomy and had a complete recovery. Tension pneumopericardium is an extremely rare condition which can be fatal if left untreated. Prompt suspicion, diagnosis, and treatment of the condition in a hemodynamically unstable trauma patient can be lifesaving.
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Current trends in the management of flail chest and the perceived role of the surgeon
J Brock Walker, Sean M Mitchell, Pierce Johnson, Joshua W Hustedt, Niloofar Dehghan, Michael D Mckee, Clifford B Jones
January-December 2019, 4(1):4-9
Background: Flail chest injuries typically occur in poly-traumatized patients and are often associated with prolonged hospital stays and high rates of morbidity and mortality. Despite multiple studies showing significantly improved outcomes with surgical fixation, the surgical community has been slow to adopt rib fixation as a part of practice and, as a result, many of these patients never undergo surgical fixation. Purpose: The purpose of this study is to determine the percentage of flail chest injuries that are being treated with surgical fixation in the United States. In addition, a survey of orthopedic trauma surgeons was conducted to assess their perception of the role of orthopedics in the treatment of patients with flail chest injuries. Methods: Patients diagnosed with a flail chest injury were identified using the National Inpatient Sample (NIS) database between 2001 and 2012 and divided into two groups based on whether or not surgical fixation of the chest wall was performed. In addition, we distributed a survey questionnaire to orthopedic trauma surgeons focusing on each individual's experience with rib fracture fixation both in training and practice. Results: A total of 45,202 patients with a flail chest injury were identified using the NIS database between 2001 and 2012. Of these, 2.1% underwent surgical fixation of the chest wall with an increase in rate of fixation from 0.8% to 3.3% over the study period. According to our survey, only 20% of orthopedic trauma surgeons performed any rib fracture fixation cases in training, and only 24% perform rib fracture fixation cases in their practice. Of those who do not perform rib fracture fixation, 72% would consider doing so if they received additional training on the topic. Of all participants surveyed, 60% believed that rib fracture fixation should be a part of the orthopedic residency curriculum and 89% believed that it should be a part of the orthopedic trauma fellowship curriculum. Conclusions: Very few flail chest injuries are being treated with surgical fixation despite the emerging literature showing improved outcomes when compared to nonoperative management. Our survey shows that there is significant interest in incorporating rib fracture fixation into surgeons' training curriculum, as well as providing specialized workshops for practicing surgeons. We hope this work encourages the surgical community to embrace rib fracture fixation as a part of our specialty so that patients with flail chest injuries receive optimal care.
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Tension pneumothorax: Are current techniques and guidelines safe?
Moheb A Rashid
January-December 2018, 3(1):19-19
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When bleeding wins clotting: The surgical dilemma in life-threatening hemothorax in hemophilia
Nisha B Jain, Sreekar Balasundaram, Joseph Sushil Rao
January-December 2018, 3(1):20-23
Due to the lack of awareness and poor access to laboratory diagnosis, hemophilia may not be diagnosed preoperatively leading to therapeutic misadventure during surgery. Hence, this congenital bleeding disorder due to Factor VIII deficiency reduces surgical management. We report a 39-year-old gentleman, diagnosed of Factor VIII deficiency who presented to emergency with acute spontaneous left hemothorax and underwent a successful thoracotomy and decortication which saved his life. He is positive for human immunodeficiency virus as well as hepatitis B for which he is on treatment. The management guidelines for thoracic surgery are not addressed to in the World Federation of Hemophilia guidelines, making the management challenging in this scenario. We report this case due to its rarity and emphasize that early recognition with immediate surgical intervention supported with Factor VIII transfusion played an important role in saving life.
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Dynamic Diaphragmatic Rupture: The Diving Stomach into the Chest
Moheb A Rashid
July-December 2016, 1(1):21-21
  1,889 3 -
A multi-institution case series of intercostal nerve cryoablation for pain control when used in conjunction with surgical stabilization of rib fractures
Frank Z Zhao, John D Vossler, Adam J Kaye
January-December 2019, 4(1):28-34
Background: Intercostal cryoneurolysis (IC) causes axonotmesis resulting in numbness distal to the nerve lesion with eventual nerve regeneration. Reported outcomes in thoracic surgery range from the majority of patients recovering normal sensation within a few weeks to some incidences of chronic neuropathic pain. We hypothesize its use can decrease pain for rib fracture patients. Methods: Multi-institution retrospective review of 13 patients who underwent surgical stabilization of rib fractures (SSRFs) with video-assisted thoracoscopy-guided IC. Demographics included mechanism of injury, number of ribs fractured and plated, and number of intercostal nerves ablated. Outcomes include pre- and post-operative pain scores, completeness of nerve function return, and dysesthesias experienced during healing. Pre- and post-operative pain scores were compared by paired t-test. Statistical significance was attributed to P < 0.05. Results: The median age was 58 (35–77) and all injuries were caused by blunt mechanism. Median number of ribs fractured was 7 (4–11). Mean time to operation was 2.1 ± 1.2 days. Median number of ribs plated was 4 (range 3–6), and the median number of intercostal nerves ablated was 6 (3–7). Eleven patients with complete pain scores were found to have mean preoperative pain of 6.9 ± 2.3 and mean postoperative pain of 4.9 ± 2.9 (P = 0.026). The mean length of stay was 8.1 ± 2.9 days after admission and 5.9 ± 2.7 days after surgery. At an average follow-up of 21.3 ± 6.2 weeks, all patients had regained some sensation. Sensation regained ranged from 10% at 16.1 weeks to 100% as early as 15.9 weeks. One patient (7.6%) developed transient severe, lifestyle limiting, hyperesthesia present at 3 months and resolved at 6 months. 8 of 13 (61.5%) patients developed transient mild-to-moderate, nonlifestyle limiting, dysesthesias. These symptoms resolved by 6 months. Conclusion: In our patients with severe rib fractures, cryoneurolysis with SSRF resulted in significantly decreased postoperative pain and approximately 70% of patients reporting some transient dysesthesias in the recovery process. While these results are encouraging, larger, prospective studies are needed to fully characterize the indications for IC.
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Chest wall injury society editorial
Thomas W White, SarahAnn S Whitbeck
January-December 2019, 4(1):3-3
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