Introduction
Flail chest is considered a highly morbid condition with reported mortality ranging from 10 to 20%. It is often associated with other severe injuries, which may complicate management and ...interpretation of outcomes. The physiologic impact and prognosis of isolated flail chest injury is poorly defined.
Methods
This is a National Trauma Databank study. All patients from 1/2007 to 12/2014 admitted with flail chest were extracted. Patients with head or abdominal AIS ≥3, dead on arrival, or transferred, were excluded. Primary outcome was mortality; secondary outcomes were need for mechanical ventilation and pneumonia.
Results
Of the 1,047,519 patients with blunt chest injury, 14,718 (1.4%) patients presented with flail chest, and 8098 (0.77%) met inclusion criteria. The most commonly associated intrathoracic injuries were hemothorax (57.9%) and lung contusions (63.0%), while sternal fracture (8.8%) and cardiac contusion (2.5%) were less common. In total, 29.8% of patients required mechanical ventilation, and 11.2% developed pneumonia. Overall mortality was 5.6%. On multivariable analysis, age >65 and need for mechanical ventilation were independent risk factors for mortality (OR 6.02, 3.75, respectively,
p
< 0.001). Independent predictors for mechanical ventilation included cardiac or pulmonary contusion and sternal fractures (OR 3.78, 2.38, 2.29, respectively,
p
< 0.001). Need for mechanical ventilation was an independent predictor of pneumonia (OR 13.18,
p
< 0.001).
Conclusions
Mortality in isolated flail chest is much lower than previously reported. Fewer than 30% of patients require mechanical ventilation. Need for mechanical ventilation, however, is independently associated with mortality and pneumonia. Age >65 is an independent risk factor for adverse outcomes, and these patients may benefit by more aggressive monitoring and treatment.
Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely ...debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality.
This National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications.
A total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%,
= 0.008), 30-day mortality (4.2 vs. 9.3%,
= 0.005), and overall mortality (7.9 vs. 13.5%,
= 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%,
= 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV-V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148-0.546;
< 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06-2.53;
= 0.026).
Despite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival.
iStar, HS-16-00883.
We hypothesized that low molecular weight heparin (LMWH) is superior to unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in patients with severe traumatic brain injuries ...(TBI).
Pharmacological VTE prophylaxis with LMWH or UH is the current standard of care in TBI. Clinical work suggests that LMWH may be more effective than UH for VTE prophylaxis in trauma patients. Experimental work shows that heparinoids may have neuroprotective properties.
ACS TQIP database study including patients with blunt severe TBI (AIS ≥ 3), those that received LMWH or UH VTE prophylaxis. Patients with severe extracranial injuries (AIS ≥ 3), death within 72 hours, or hospital stay <48 hours were excluded. Demographic and clinical data on admission was collected, as well as head, thorax, and abdomen AIS, and timing of prophylaxis (within 48 hours, 49-72 hours, and >72 hours). Outcomes included VTE complications, mortality, and unplanned return to the operating room. Multivariate analysis was performed to compare outcomes between patients receiving LMWH and UH.
Overall, 20,417 patients met the criteria for inclusion in the study, 10,018 (49.1%) received LMWH and 10,399 (50.9%) UH. Multivariate analysis showed that LMWH was an independent protective factor against mortality and thromboembolic complications, regardless of timing of prophylaxis initiation. The type of prophylaxis had no effect on the need for unplanned return to the operating room.
LMWH prophylaxis in severe TBI is associated with better survival and lower thromboembolic complications than UH.
•Early (<72 h) VTE prophylaxis after severe pelvic fracture is associated with lower rates of VTE.•LMWH, relative to unfractionated heparin, is associated with lower rates of VTE and lower ...mortality.•In contemporary practice, early VTE prophylaxis is given safely in nearly ¾ of patients with severe pelvic fractures.
Introduction: Optimal timing of pharmacological thromboprophylaxis (VTEp) in patients with severe pelvic fractures remains unclear. The high risk of venous thromboembolic (VTE) complications after severe pelvic fractures supports early VTEp however concern for fracture-associated hemorrhage can delay initiation. Patients with pelvic fractures also frequently have additional injuries that complicate the interpretation of the VTEp safety profiles. To minimize this problem, the study included only patients with isolated severe pelvic fractures.
Materials and methods: The Trauma Quality Improvement Program was used to collect patients with blunt severe pelvic fractures (AIS > 3) who received VTEp with unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients with head, chest, spine, and abdominal injuries AIS > 3, or those with angio or operative intervention prior to VTEp were excluded. The study population was stratified according to timing of VTEp, early (<48 h) and late (>48 h). Outcomes included in-hospital mortality and VTE.
Results: 2752 patients were included in the study. Overall, 2007 patients (72.9%) received early VTEp, while 745 (27.1%) received late VTEp. LMWH was administered in 2349 (85.4%) and UH in 403 (14.6%).
Late VTEp was associated with significantly higher incidence of VTE (4.3% vs. 2.2%, p = 0.004). Logistic regression identified late VTEp as an independent risk factor for VTE (OR 1.93, p = 0.009) and mortality (OR 4.03, p = 0.006). LMWH was an independent factor protective for both VTE and mortality (OR 0.373, p < 0.001, OR 0.266, p = 0.009, respectively).
Conclusion: In isolated severe pelvic fractures, early VTEp is independently associated with improved survival and fewer VTE. LMWH may be preferred over UH for this purpose.
Abstract Background Major trauma to the pancreas is uncommon, but associated with significant overall morbidity and mortality. A vast majority of these adverse outcomes can be attributed to the ...presences of associated injuries. Among those patients who survive the initial injury, however, the subsequent development of pancreas-related complications represents a significant source of adverse outcomes. Methods and results A total of 257 patients admitted from January 1996 to April 2007 were identified from the trauma registry database at our institution. One hundred and eighty-three patients surviving more than 48 h after admission were selected for analysis. These patients were grouped according to the surgical management utilised to address their pancreatic injuries: either resection or operative drainage. After exclusion of patients with associated vascular injuries, those undergoing drainage had lower rate of associated hollow viscus injuries (51.9% vs. 69.9%; p = 0.016) and lower rates of associated solid organ injuries (44.2% vs. 70.9%; p ≤ 0.001). Patients undergoing drainage were noted to have a higher incidence of pseudocyst formation (19.5% vs. 9.0%; OR: 2.47, 95% CI, 0.92–6.67; p = 0.068), but lower hospital lengths of stay (18.7 ± 18.5 vs. 33.8 ± 63.5; p = 0.001). No difference in mortality was noted between the two populations (5.7% vs. 3.0%; p = 0.700). After multivariate analysis pseudocyst formation was the only complication that proved different between the two management groups, with patients undergoing operative drainage more commonly developing this adverse sequela (OR: 2.93, 95% CI, 1.02–8.36; p = 0.041). Conclusions In the absence of vascular injury, the choice of surgical management did not affect adjusted mortality or the overall occurrence of pancreas-related complications. Individuals treated with operative drainage alone, however, were significantly more likely to develop a post-operative pseudocyst than their resectional counterparts.
Motocross-related injury patterns and outcomes are poorly understood. The purpose of this analysis was to characterize the epidemiology, injury patterns, and outcomes of motocross collisions. These ...parameters were compared with motorcycle collisions for context.
The National Trauma Databank (NTDB) (2007-14) was used to identify and compare injured motorcycle and motocross riders. Variables extracted were demographics, Abbreviated Injury Scale for each body area, Injury Severity Score, and emergency department vital signs. Outcomes included mortality, ventilation days, intensive care unit length of stay, and hospital length of stay.
Of the 5,774,836 NTDB patients, 141,529 were involved in motocross or motorcycle collisions (31,252 motocross and 110,277 motorcycle). Overall, 94.4% were drivers and 87.4% were male. Motocross riders were younger (23 vs. 42, p < 0.001), more likely to use helmets (68.9% vs. 54.1%, p < 0.001), and less likely to have used alcohol (8.4% vs. 23.0%, p < 0.001). Head and chest injuries were less common in motocross patients (28.6% vs. 37.2%, p < 0.001; 25.5% vs. 37.7%, p < 0.001, respectively), as were Injury Severity Score of greater than 15 and Glasgow Coma Scale of less than or equal to 8 (18.2% vs. 28.1%, p < 0.001; 3.7% vs. 7.7%, p < 0.001, respectively). Overall mortality was significantly lower in the motocross group (0.3% vs. 1.4%, p < 0.001). Stepwise logistic regression analysis identified age of older than 60 years, Glasgow Coma Scale of less than or equal to 8, hypotension on admission, head Abbreviated Injury Scale of greater than or equal to 3, and riding a motorcycle, either as a driver or passenger, to be independent predictors of mortality. Subgroup analysis revealed being a motocross driver or passenger to be an independent predictor of improved survival (odds ratio OR, 0.458; 95% confidence interval CI, 0.359-0.585; p < 0.001 and OR, 0.127; CI 95%, 0.017-0.944; p = 0.044, respectively). Helmets were protective against mortality for all patients (OR, 0.866; 95% CI, 0.755-0.992; p = 0.039).
Motocross and motorcycle collisions are distinct mechanisms of injury. Motocross riders are younger, more likely to wear protective devices, and less likely to use alcohol. Motocross collisions are associated with better outcomes compared with motorcycle collisions. Wearing a helmet is associated with improved survival for all riders.
Retrospective epidemiological study, level IV.
The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural ...hematomas (ASDH).
Matched cohort study using ACS-TQIP database (2013–2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis.
In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH.
Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.
•Timing of VTEp has no effect on mortality or delayed craniectomy in patients with acute subdural hematomas.•Early VTEp (≤48 h) is associated with less thromboembolism complications compared to late VTEp (>48 h).•LMWH is independently associated with a lower mortality compared to UH.
The optimal chest tube size for the drainage of traumatic hemothoraces and pneumothoraces is unknown. The purpose of this study was to compare the efficacy of small versus large chest tubes for use ...in thoracic trauma. Our hypothesis was that (1) there would be no difference in clinically relevant outcomes including retained hemothoraces, the need for additional tube insertion, and invasive procedures and (2) there would be an increase in pain with the insertion of large versus small tubes.
This is a prospective, institutional review board-approved observational study. All patients requiring open chest tube drainage within 12 hours of admission (January 2007-January 2010) were identified at a Level I trauma center. Clinical demographic data and outcomes including efficacy of drainage, complications, retained hemothoraces, residual pneumothoraces, need for additional tube insertion, video-assisted thoracoscopy, and thoracotomy were collected and analyzed by tube size. Small chest tubes (28-32 Fr) were compared with large (36-40 Fr).
During the study period, a total of 353 chest tubes (small: 186; large: 167) were placed in 293 patients. Of the 275 chest tubes inserted for a hemothorax, 144 were small (52.3%) and 131 were large (47.7%). Both groups were similar in age, gender, and mechanism; however, large tubes were placed more frequently in patients with a Glasgow Coma Scale ≤8, severe head injury, a systolic blood pressure <90 mm Hg, and Injury Severity Score ≤25. The volume of blood drained initially and the total duration of tube placement were similar for both groups (small: 6.3 ± 3.9 days vs. large: 6.2 ± 3.6 days; adjusted (adj.) p = 0.427). After adjustment, no statistically significant difference in tube-related complications, including pneumonia (4.9% vs. 4.6%; adj. p = 0.282), empyema (4.2% vs. 4.6%; adj. p = 0.766), or retained hemothorax (11.8% vs. 10.7%; adj. p = 0.981), was found when comparing small versus large chest tubes. The need for tube reinsertion, image-guided drainage, video-assisted thoracoscopy, and thoracotomy was likewise the same (10.4% vs. 10.7%; adj. p = 0.719). For patients with a pneumothorax requiring chest tube drainage (n = 238), there was no difference in the number of patients with an unresolved pneumothorax (14.0% vs. 13.0%; adj. p = 0.620) or those needing reinsertion of a second chest tube. The mean visual analog pain score was similar for small and large tubes (6.0 ± 3.3 and 6.7 ± 3.0; p = 0.237).
For injured patients with chest trauma, chest tube size did not impact the clinically relevant outcomes tested. There was no difference in the efficacy of drainage, rate of complications including retained hemothorax, need for additional tube drainage, or invasive procedures. Furthermore, tube size did not affect the pain felt by patients at the site of insertion.
: II.
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