RESUMEN
INTRODUCTION: Point of care ultrasound has long been used in the trauma setting for rapid assessment and diagnosis of critically ill patients. Its utility for diagnosis of pericardial effusion in the setting of penetrating thoracic trauma has more recently been a topic of consideration, given the rapid decompensation that these patients can experience. OBJECTIVES: This study aims to identify the diagnostic accuracy of point of care ultrasound in the diagnosis of pericardial effusion among patients with penetrating thoracic trauma. METHODS: Retrospective review of 2099 patients brought to the trauma bay between the years 2016 and 2021 were analyzed for diagnosis of pericardial effusion. Patients who were diagnosed with a pericardial effusion were investigated for point of care ultrasound findings. Descriptive statistics were performed to identify sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Prevalence was calculated to be 26.7 cases of pericardial effusion per 1000 patients presenting with penetrating thoracic trauma. Incidence was estimated to be 3.8 cases of pericardial effusion per 1000 person-years. Calculation of diagnostic capabilities of ED POCUS revealed a sensitivity of 96.36 â%, a specificity of 100 â%, PPV of 100 â%, and NPV of 99.90 â%. CONCLUSIONS: Point of Care cardiac ultrasonography is a reliable tool for the rapid diagnosis of pericardial effusion in penetrating thoracic trauma patients. Patients with ultrasound suggestive of this condition should receive rapid surgical management to prevent decompensation.
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Evaluación Enfocada con Ecografía para Trauma , Derrame Pericárdico , Traumatismos Torácicos , Centros Traumatológicos , Heridas Penetrantes , Humanos , Derrame Pericárdico/diagnóstico por imagen , Derrame Pericárdico/etiología , Estudios Retrospectivos , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagen , Heridas Penetrantes/diagnóstico por imagen , Heridas Penetrantes/complicaciones , Masculino , Femenino , Adulto , Sensibilidad y Especificidad , Persona de Mediana Edad , Sistemas de Atención de Punto , UltrasonografíaRESUMEN
OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for severe blunt thoracic aortic injuries (BTAI). Successful outcomes rely on accurate endograft sizing, but initial imaging may underestimate aortic diameters. This study examines the impact of intravascular ultrasound (IVUS) on endograft sizing and clinical outcomes in BTAI patients. METHODS: A prospectively collected multi-institutional dataset from the Aortic Trauma Foundation was analyzed. Patients with BTAI undergoing TEVAR with IVUS were compared to patients who underwent TEVAR alone. Demographics and operative variables were compared, focusing on IVUS effects on endograft sizing by examining maximal proximal and distal aortic diameter on initial CT imaging compared to the graft diameters used during TEVAR. RESULTS: 293 patients underwent TEVAR for BTAI with IVUS utilized in 124 cases (42.3%). The average graft size in the IVUS and non-IVUS groups were similar proximally (26.91 ± 4.3 mm IVUS vs 27.77 ± 4.7 mm non-IVUS, P = 0.116) and distally (25.96 ± 4.7 mm IVUS vs 26.51 ± 4.7 mm non-IVUS). IVUS did not impact the difference between graft size and initial CT measurements proximally (4.32 ± 4.8 mm IVUS vs 4.23 ± 3.9 mm non-IVUS, P = 0.859) or distally (4.17 ± 5.9 mm IVUS vs 4.50 ± 4.3 mm non-IVUS, P = 0.606). Although delayed hemorrhagic and ischemic stroke occurred less frequently in IVUS patients (0.8% IVUS vs 7.1% non- IVUS, P = 0.024), in-hospital mortality was similar between groups (5.6% IVUS vs 7.7% non-IVUS, P = 0.581). CONCLUSIONS: IVUS is not associated with significant changes in endograft sizing compared to sizing based on CT scan alone in BTAI patients. IVUS was not associated with differences in mortality but was associated with a decrease in delayed hemorrhagic and ischemic stroke. Routine IVUS in BTAI patients may not be necessary for accurate sizing, but there may be a relationship between IVUS and stroke.
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Aorta Torácica , Implantación de Prótesis Vascular , Prótesis Vascular , Procedimientos Endovasculares , Valor Predictivo de las Pruebas , Diseño de Prótesis , Ultrasonografía Intervencional , Lesiones del Sistema Vascular , Heridas no Penetrantes , Humanos , Masculino , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/mortalidad , Femenino , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/mortalidad , Persona de Mediana Edad , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Adulto , Bases de Datos Factuales , Estudios Retrospectivos , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/mortalidad , Factores de Riesgo , Factores de Tiempo , Estados Unidos , Anciano , Aortografía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/mortalidadRESUMEN
This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.
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Cuidados Críticos , Traumatismos Torácicos , Humanos , Cuidados Críticos/métodos , Traumatismos Torácicos/terapia , Traumatismos Torácicos/diagnóstico por imagen , Manejo del Dolor/métodosAsunto(s)
Traumatismos Abdominales , Medios de Contraste , Traumatismos Torácicos , Humanos , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugía , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/diagnóstico , Adulto , Niño , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS: A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS: Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION: For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.
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Hemotórax , Heridas no Penetrantes , Humanos , Estudios Retrospectivos , Masculino , Femenino , Adulto , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnóstico por imagen , Persona de Mediana Edad , Hemotórax/etiología , Hemotórax/terapia , Tomografía Computarizada por Rayos X , Traumatismos Torácicos/terapia , Traumatismos Torácicos/diagnóstico por imagen , Drenaje , Factores de Riesgo , Fracturas de las Costillas/terapia , Fracturas de las Costillas/diagnóstico por imagenRESUMEN
INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.
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Tubos Torácicos , Remoción de Dispositivos , Neumotórax , Toracostomía , Ultrasonografía , Humanos , Neumotórax/etiología , Neumotórax/diagnóstico por imagen , Toracostomía/instrumentación , Toracostomía/efectos adversos , Toracostomía/métodos , Masculino , Femenino , Estudios Prospectivos , Adulto , Persona de Mediana Edad , Tubos Torácicos/efectos adversos , Radiografía Torácica , Adulto Joven , Hemotórax/etiología , Hemotórax/diagnóstico por imagen , Hemotórax/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico , Anciano , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagenRESUMEN
Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.
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Medios de Contraste , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Heridas no Penetrantes , Humanos , Masculino , Heridas no Penetrantes/diagnóstico por imagen , Femenino , Adulto , Estudios Retrospectivos , Persona de Mediana Edad , Traumatismos Torácicos/diagnóstico por imagen , Pelvis/lesiones , Pelvis/diagnóstico por imagen , Pelvis/irrigación sanguínea , Traumatismos Abdominales/diagnóstico por imagen , COVID-19/epidemiologíaRESUMEN
INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.
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Traumatismos Abdominales , Sistemas de Atención de Punto , Traumatismos Torácicos , Ultrasonografía , Heridas Punzantes , Humanos , Heridas Punzantes/diagnóstico por imagen , Heridas Punzantes/cirugía , Masculino , Adulto , Femenino , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Abdominales/diagnóstico por imagen , Estudios Retrospectivos , Toracotomía/métodos , Algoritmos , Tomografía Computarizada por Rayos X , Laparoscopía , Esternotomía , Incertidumbre , Adulto JovenAsunto(s)
Traumatismos Torácicos , Insuficiencia de la Válvula Tricúspide , Humanos , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/cirugía , Masculino , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/complicaciones , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/lesiones , Válvula Tricúspide/cirugía , Persona de Mediana Edad , AdultoRESUMEN
One of the principles of managing trauma patients is that of their continuous re-evaluation over the hours and days. Even if the execution of the computed tomography method is classically recommended, especially in the most serious cases and in polytraumas with major dynamics, the clinician can use or request an ultrasound examination, especially in subsequent re-evaluations. Here we report a clinical case demonstrating how an ultrasound re-evaluation after the acute event can lead to a correct diagnosis of a rare complication of thoracic trauma. The findings were suggestive for a pseudoaneurysm of the internal right mammary artery. Subsequently, an ultrasound-guided injection of thrombin was carried out until complete interruption of the flow within the formation. At subsequent follow-up, no arterial or venous blush was highlighted.
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Aneurisma Falso , Arterias Mamarias , Humanos , Aneurisma Falso/diagnóstico por imagen , Arterias Mamarias/diagnóstico por imagen , Masculino , Ultrasonografía/métodos , Adulto , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/complicacionesRESUMEN
Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fractures. More studies have claimed that early video-assisted thoracoscopic surgery with surgical stabilization of rib fractures (SSRF) results in a good prognosis in patients with major trauma. This study aimed to verify the outcomes in patients with chest trauma whether SSRF was performed. Consecutive patients who were treated in a medical center in Taiwan, for traumatic events between January 2015 and June 2020, were retrospectively reviewed. This study focused on patients with major trauma and thoracic injuries, and they were divided into groups based on whether they received SSRF. We used electrical impedance tomography (EIT) to evaluate the change of ventilation conditions. Different scores used for the evaluation of trauma severity were also compared in this study. Among the 8396 patients who were included, 1529 (18.21%) had major trauma with injury severity score > 16 and were admitted to the intensive care unit initially. A total of 596 patients with chest trauma were admitted, of whom 519 (87%) survived. Younger age and a lower trauma score (including injury severity scale, new injury severity score, trauma and injury severity score, and revised trauma score) account for better survival rates. Moreover, 74 patients received SSRF. They had a shorter intensive care unit (ICU) stay (5.24, p = 0.045) and better performance in electrical impedance tomography (23.46, p < 0.001). In patients with major thoracic injury, older age and higher injury survival scale account for higher mortality rate. Effective surgical stabilization of rib fractures shortened the ICU stay and helped achieve better performance in EIT. Thoracoscope-assisted rib fixation is suggested in severe trauma cases.
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Impedancia Eléctrica , Fracturas de las Costillas , Traumatismos Torácicos , Humanos , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/diagnóstico por imagen , Femenino , Masculino , Persona de Mediana Edad , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/diagnóstico por imagen , Adulto , Estudios Retrospectivos , Anciano , Resultado del Tratamiento , Cirugía Torácica Asistida por Video/métodos , Puntaje de Gravedad del Traumatismo , Tomografía/métodosRESUMEN
BACKGROUND: The trauma-related pneumothorax is a common intrathoracic injury and can go undetected with detrimental outcomes. Chest computed tomography (CT) investigation in low- to middle-income countries (LMIC) is not always readily available during emergency situations and increased workloads. However, alternative investigations all have limitations in including pneumothoraces. Patients may have trauma indications for CT of the head and neck. The neck CT scan may hold an extra potential advantage in pneumothorax detection. This study aimed to assess its sensitivity in pneumothorax detection in nonpenetrating trauma. METHODS: A retrospective study was conducted from 1 January 2016 to 31 December 2021. All adult patients sustaining nonpenetrating injuries, and investigated with chest and neck CT scans were included. The chest CT scan was the gold standard against,which the neck CT scan was compared to determine the accuracy of pneumothorax detection. Stata version 16 was used for descriptive statistical analysis, and a p-value of 0.05 was considered statistically significant. RESULTS: One thousand ninety three were eligible for evaluation; 204 (18.66%) pneumothoraces were detected on chest CT scans, 200 (98.0%) of which were also detected on the neck CT scan, producing a sensitivity of 98.0% (95% CI 95.1-99.5%) and a specificity of 100% (95% CI 99.6-100%). Most pneumothoraces were detected at T1 level (45.09%), followed by T2 (43.62%). CONCLUSION: The neck CT scan has demonstrated high sensitivity and specificity in pneumothorax detection. Thus, it may be used as an additional tool for those who could not receive or do not need a formal chest CT but have an indication for neck CT scans.
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Neumotórax , Traumatismos Torácicos , Heridas no Penetrantes , Adulto , Humanos , Neumotórax/diagnóstico por imagen , Neumotórax/etiología , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagenRESUMEN
BACKGROUND: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.
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Aorta Torácica , Implantación de Prótesis Vascular , Prótesis Vascular , Procedimientos Endovasculares , Diseño de Prótesis , Lesiones del Sistema Vascular , Heridas no Penetrantes , Humanos , Masculino , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Femenino , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/mortalidad , Lesiones del Sistema Vascular/etiología , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Aorta Torácica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Adulto , Resultado del Tratamiento , Persona de Mediana Edad , Factores de Tiempo , Estudios Prospectivos , Adulto Joven , Anciano , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/mortalidad , Estados Unidos , Stents , Factores de RiesgoAsunto(s)
Aorta Torácica , Implantación de Prótesis Vascular , Prótesis Vascular , Procedimientos Endovasculares , Heridas no Penetrantes , Humanos , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Aorta Torácica/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/etiología , Heridas no Penetrantes/complicaciones , Masculino , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Stents/efectos adversos , Resultado del Tratamiento , Lesiones del Sistema Vascular/cirugía , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/cirugía , Oclusión de Injerto Vascular/diagnóstico por imagen , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagen , Diseño de PrótesisRESUMEN
BACKGROUND: Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. METHODS: We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. RESULTS: There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. CONCLUSION: Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Tubos Torácicos , Neumotórax , Radiografía Torácica , Traumatismos Torácicos , Toracostomía , Humanos , Toracostomía/métodos , Toracostomía/instrumentación , Neumotórax/diagnóstico por imagen , Neumotórax/etiología , Neumotórax/cirugía , Estudios Retrospectivos , Masculino , Femenino , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/cirugía , Adulto , Radiografía Torácica/métodos , Persona de Mediana Edad , Tomografía Computarizada por Rayos X/métodos , Valor Predictivo de las Pruebas , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagen , Puntaje de Gravedad del TraumatismoRESUMEN
INTRODUCTION: Zambia is experiencing a critical shortage of radiologists responsible for interpreting X-ray images. Nine radiologists serve the entire population of over 18 million people. Consequently, referring physicians can receive reports late and often receive X-ray images without radiological reports attached, which may lead to delayed diagnoses and treatment of critically injured patients. This challenge could be alleviated if radiographers could assist with interpreting X-ray images. This study was undertaken to subject a cohort of Zambian radiographers to a training intervention, however, the COVID-19 pandemic necessitated using a novel approach to the intervention by delivering the training mainly through social media but also through face-to-face lectures. METHODS: A cohort of 27 radiographers employed at eight public hospitals in the Copperbelt Province of Zambia undertook a training intervention using face-to-face training and image discussions on the social media WhatsApp® platform. The participants underwent a pre-and post-test in which they were asked to interpret 20 adult trauma CXR images. For the training intervention, the radiographers attended a face-to-face image interpretation lecture, after which they received training images with a radiologist report weekly for eight weeks via the WhatsApp® platform. Participants were encouraged to discuss and pose questions via the platform. RESULTS: The cohort of radiographers (n = 27) showed an improvement in their interpretation skills for trauma CXR images. The interpretation median scores ranged from approximately 82% to 93% in the pre-test and 85% to 97% in the post-test. The Wilcoxon signed-rank tests revealed significant differences in the interpretation ability skills for 12 of the 20 CXR images after the 8-week training, demonstrating the successful implementation of the program. When comparing three categories of radiographers' years of experience (1-5; >5-10; and >10 years), the Kruskal Wallis test could not identify significant differences in the CXR image interpretation skills among the different categories of experience (P = 0.1616). When comparing the interpretation skills of radiographers working at the three different hospital levels (Level 3 with a full-time radiologist and more than ten radiographers; Level 1 and 2 without a full-time radiologist; Level 2 with six to ten radiographers; and Level 1 with five or less radiographers), the Kruskal Wallis test revealed that the level of the hospital where the radiographers were employed significantly influenced their skills to interpret the CXR images (P = 0.0323). CONCLUSION: This type of novel training intervention is urgently required in the Copperbelt Province of Zambia. The results show that the training process was implemented successfully to improve radiographers' image interpretation skills of adult trauma CXR images. IMPLICATIONS FOR PRACTICE: Promoting radiographers' involvement in image interpretation will likely improve imaging services in Zambia, considering the critical shortage of radiologists.
Asunto(s)
Competencia Clínica , Radiografía Torácica , Humanos , Zambia , Masculino , Adulto , Femenino , Medios de Comunicación Sociales , Radiólogos/educación , Estudios de Cohortes , Traumatismos Torácicos/diagnóstico por imagen , Radiología/educación , COVID-19/diagnóstico por imagenRESUMEN
A five-year-old boy was diagnosed with the ventricular septal rupture and ventricular aneurysm after blunt chest trauma in child abuse. Because of the intractable heart failure, he underwent operation in subacute period. Postoperative course was uneventful. The blunt cardiac injury in children can be caused by mild trauma and can be lethal. Surgical intervention should be considered when the clinical condition is unstable.
Asunto(s)
Aneurisma Cardíaco , Insuficiencia Cardíaca , Traumatismos Torácicos , Rotura Septal Ventricular , Heridas no Penetrantes , Preescolar , Humanos , Masculino , Aneurisma Cardíaco/diagnóstico por imagen , Aneurisma Cardíaco/etiología , Aneurisma Cardíaco/cirugía , Insuficiencia Cardíaca/etiología , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagen , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/cirugía , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagenAsunto(s)
Hernia , Enfermedades Pulmonares , Humanos , Hernia/diagnóstico por imagen , Hernia/etiología , Enfermedades Pulmonares/etiología , Enfermedades Pulmonares/diagnóstico por imagen , Masculino , Enfermedades Pleurales/diagnóstico por imagen , Enfermedades Pleurales/etiología , Herniorrafia , Tomografía Computarizada por Rayos X , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico por imagenRESUMEN
OBJECTIVES: The aim of the study was to describe clinical examination and thoracic CT (TCT) findings in cats after trauma, and to identify physical examination findings associated with both abnormalities on TCT and the need for therapeutic interventions. METHODS: A multicentre, retrospective, observational study was conducted. Cats admitted to the participating hospitals with a history of blunt trauma and that underwent TCT were eligible. Data were collected on signalment, history, physical examination, TCT findings and subsequent interventions. RESULTS: In total, 137 cats were included. Road traffic accidents (RTAs) were the most frequently reported cause of trauma (69%). Tachypnoea (32%), pale mucous membranes (22%) and dyspnoea (20%) were the most common abnormal findings on thoracic examination. The most frequently identified thoracic pathologies on TCT were atelectasis (34%), pulmonary contusions (33%), pneumothorax (29%) and pleural effusion (20%). Thoracocentesis was the most commonly performed intervention (12%), followed by chest drain placement (7%). A total of 45 (33%) cats had no physical examination abnormalities but did have abnormalities detected on TCT; six of these cats required interventions. Increasing numbers of thoracic abnormalities on clinical examination were associated with increasing likelihood of having abnormal findings on TCT (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.21-3.44, P = 0.008) and of requiring an intervention (OR 1.82, 95% CI 1.32-2.51, P <0.001). CONCLUSIONS AND RELEVANCE: RTAs were the most common reported cause of blunt trauma. Atelectasis, pulmonary contusions and pneumothorax were the most common abnormalities identified on TCT, and thoracic drainage was the most utilised intervention. TCT may be useful in identifying cats with normal thoracic physical examination findings that have significant thoracic pathology, and a high number of abnormal findings on thoracic examination should raise suspicion for both minor and major thoracic pathology. The results of this study can be used to assist in selecting appropriate cases for TCT after blunt trauma.