Selective nonoperative management of penetrating thoracic injury

Waes, Oscar J.F. Van; Halm, Jens A.; Imhoff, Diederik I. Van; Navsaria, Pradeep; Nicol, Andrew; Verhofstad, Michael H.J.; Vermeulen, Jefrey

doi:10.1097/mej.0000000000000401

Cited by 14 publications

(23 citation statements)

References 31 publications

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“…Longer chest drainage times increase the rates of complications (Huang, Lu, Yang, Chou, & Lin, ). The complication rate of chest drainage ranges from 4.8% to 22.3% (Ball et al, ; Van Waes, Halm, Van Imhoff, Navsaria, Nicol, Verhofstad, Vermeulen, ) . Among the main complications are placement of the drain in the intraparenchymal region of the lung, empyema, and infection at the site of tube insertion (Ball et al, ).…”

Section: Introductionmentioning

confidence: 99%

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Comparing high and low levels of continuous positive airway pressure on lung aeration in patients with pleural drainage: A feasibility study for a randomized controlled trial

Santos

Campos

Carmo

et al. 2018

Physiotherapy Res Intl

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Objective:We explored the feasibility of use of continuous positive airway pressure (CPAP) with 15-and 4-cmH 2 O for a randomized controlled trial with patients with pleural drainage.Methods: Ten patients with traumatic pleural effusion drained within 24 hr, with controlled pain received randomly CPAP with 0-, 4-, and 15-cmH 2 O. Computed tomography was used to assess the lung aeration. Patients reported the level of tolerability. Air leak was also observed as a parameter of safety. The levels of pressure were compared using the Friedman test followed by the Tukey test as post hoc. Results:The lung area under CPAP with 15 cmH 2 O (median = 3,913 mm 2 ; IQR = 3,416-4,390 mm 2 ) was greater than 4 (median = 3,495 mm 2 ; IQR = 3,075-3,954 mm 2 ) and 0 cmH 2 O (median = 3,382 mm 2 ; IQR = 2,962-3,658 mm 2 ; p < 0.001). There was no difference between lung areas under CPAP with 4 and 0 cmH 2 O. All levels of pressure were well tolerated by patients. No air leak was observed during the assessments.Conclusion: CPAP with 15 cmH 2 O is able to expand lungs of patients with pleural drainage. CPAP with 4 cmH 2 O seems not have therapeutic effect. In addition, CPAP with 15 cmH 2 O is well tolerated and safe in this population. KEYWORDScontinuous positive airway pressure, computerized tomography, pleural effusion, thoracic surgery

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Section: Introductionmentioning

confidence: 99%

“…Among the main complications are placement of the drain in the intraparenchymal region of the lung, empyema, and infection at the site of tube insertion (Ball et al, ). These complications can increase the length of hospital stay (Holbek, Hansen, Kehlet, & Petersen, ) and lead to a mortality rate of 2% (Van Waes et al, ).…”

Section: Introductionmentioning

confidence: 99%

Comparing high and low levels of continuous positive airway pressure on lung aeration in patients with pleural drainage: A feasibility study for a randomized controlled trial

Santos

Campos

Carmo

et al. 2018

Physiotherapy Res Intl

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“…A study from Cape Town quotes a national figure which estimates that thoracic trauma contributes approximately one-fifth of all non-natural causes of death in South Africa. 4 Across the UK, PTT accounts for 25% of approximately 4000 trauma-related deaths each year. 5 These figures demonstrate the potential impact that PTT has on our societies and healthcare systems.…”

Section: Introductionmentioning

confidence: 99%

“…The majority of patients with PTT who reach hospital can be managed conservatively, either by observation or by means of tube thoracostomy. 4,6,8 Identifying patients who can safely be observed, those who require tube thoracostomy alone and those who require surgery is key to the successful management of these injuries. When the incorrect management algorithm is followed there is the potential that some patients may have delayed surgical treatment and, conversely, that some patients may be subjected to unnecessary intervention.…”

Section: Introductionmentioning

confidence: 99%

A selective non-operative approach to thoracic stab wounds is safe and cost effective – a South African experience

Dayananda

Kong

Bruce

et al. 2018

annals

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Introduction Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma. Materials and methods The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms. Results Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310). Discussion Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms. Conclusion Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.

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“…Un taux similaire de mortalité intra-hospitalière est retrouvé dans une cohorte de plus de 23 000 patients militaires américains blessés de 2003 à 2008 et est comparable à celui retrouvé dans la population américaine civile sur la même période(11). D'autres études civiles rapportent un taux de mortalité chez les patients victimes de TTP variant de 2,1 à 52%(50,46,73,76,127,62,132). En Europe, dans une série hollandaise civile, Heus et al décrit un taux de mortalité à 30 jours de 7,5%, avec un score ISS moyen de 12(50).…”

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Penetrating thoracic injuries: a retrospective analysis from a French military trauma centre

et al. 2019

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BackgroundPenetrating thoracic injuries (PTIs) is a medicosurgical challenge for civilian and military trauma teams. In civilian European practice, PTIs are most likely due to stab wounds and mostly require a simple chest tube drainage. On the battlefield, combat casualties suffer severe injuries, caused by high-lethality wounding agents.The aim of this study was to analyse and compare the demographics, injury patterns, surgical management and clinical outcomes of civilian and military patients with PTIs.MethodsAll patients with PTIs admitted to a Level I Trauma Centre in France or to Role-2 facilities in war theatres between 1 January 2004 and 31 May 2016 were included. Combat casualties’ data were analysed from Role-2 medical charts. The hospital manages military casualties evacuated from war theatres who had already received primary surgical care, but also civilian patients issued from the Paris area. During the study period, French soldiers were deployed in Afghanistan, in West Africa and in the Sahelo-Saharan band since 2013.Results52 civilian and 17 military patients were included. Main mechanisms of injury were stab wounds for civilian patients, and gunshot wounds and explosive fragments for military casualties. Military patients suffered more severe injuries and needed more thoracotomies. In total, 29 (33%) patients were unstable or in cardiac arrest on admission. Thoracic surgery was performed in 38 (55%) patients (25 thoracotomies and 13 thoracoscopies). Intrahospital mortality was 18.8%.ConclusionWar PTIs are associated with extrathoracic injuries and higher mortality than PTIs in the French civilian area. In order to reduce the mortality of PTIs in combat, our study highlights the need to improve tactical en route care with transfusion capabilities and the deployment of forward surgical units closer to the combatants. In the civilian area, our results indicated that video-assisted thoracoscopic surgery is a reliable diagnostic and therapeutic technique for haemodynamically stable patients.

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Selective nonoperative management of penetrating thoracic injury

Cited by 14 publications

References 31 publications

Comparing high and low levels of continuous positive airway pressure on lung aeration in patients with pleural drainage: A feasibility study for a randomized controlled trial

Comparing high and low levels of continuous positive airway pressure on lung aeration in patients with pleural drainage: A feasibility study for a randomized controlled trial

A selective non-operative approach to thoracic stab wounds is safe and cost effective – a South African experience

Penetrating thoracic injuries: a retrospective analysis from a French military trauma centre

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