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Stojanovska J, Hurwitz Koweek LM, Chung JH, Ghoshhajra BB, Walker CM, Beache GM, Berry MF, Colletti PM, Davis AM, Hsu JY, Khosa F, Kicska GA, Kligerman SJ, Litmanovich D, Maroules CD, Meyersohn N, Syed MA, Tong BC, Villines TC, Wann S, Wolf SJ, Kanne JP, Abbara S. ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol 2020; 17:S380-S390. [PMID: 33153551 DOI: 10.1016/j.jacr.2020.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Blunt cardiac injuries range from myocardial concussion (commotio cordis) leading to fatal ventricular arrhythmias to myocardial contusion, cardiac chamber rupture, septal rupture, pericardial rupture, and valvular injuries. Blunt injuries account for one-fourth of the traumatic deaths in the United States. Chest radiography, transthoracic echocardiography, CT chest with and without contrast, and CT angiography are usually appropriate as the initial examination in patients with suspected blunt cardiac injury who are both hemodynamically stable and unstable. Transesophageal echocardiography and CT heart may be appropriate as examination in patients with suspected blunt cardiac injuries. This publication of blunt chest trauma-suspected cardiac injuries summarizes the literature and makes recommendations for imaging based on the available data and expert opinion. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | | | - Garth M Beache
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Mark F Berry
- Stanford University Medical Center, Stanford, California; The Society of Thoracic Surgeons
| | | | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | | | - Mushabbar A Syed
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois; Society for Cardiovascular Magnetic Resonance
| | - Betty C Tong
- Duke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Wisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert
| | - Stephen J Wolf
- Denver Health MC/UPI, Denver, Colorado; American College of Emergency Physicians
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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Long B, Long DA, Tannenbaum L, Koyfman A. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. Am J Emerg Med 2020; 38:998-1006. [DOI: 10.1016/j.ajem.2019.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
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Surgical Emphysema in a Pediatric Tertiary Referral Center. Pediatr Emerg Care 2020; 36:e21-e24. [PMID: 30672901 DOI: 10.1097/pec.0000000000001725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laryngeal trauma in pediatrics is extremely rare; however, because of the smaller pediatric larynx, it can have catastrophic consequences. Following laryngeal trauma, surgical emphysema is a relatively common presentation. In pediatrics, it can be a life-threatening condition. Here we describe 2 cases of laryngeal trauma resulting in extensive surgical emphysema. CASES The first case described involves bilateral pneumothoraces, airway compromise, and respiratory arrest and was managed with bilateral chest drains, intubation, and tracheostomy. The second case resulted in widespread surgical emphysema in a stable patient and was managed conservatively. Both cases were monitored closely for a period of time to ensure there were no further sequelae. DISCUSSION Patients with laryngeal trauma resulting in surgical emphysema have the potential to deteriorate rapidly. Furthermore, surgical emphysema degrades the quality of ultrasound images, which may delay the diagnosis. If there are any concerns about the safety of the airway, then it should be secured definitively with either endotracheal intubation or emergency tracheostomy depending on clinical judgment. It is acceptable to monitor patients closely in a high-dependency unit setting if they are stable and do not show any evidence of laryngeal edema. CONCLUSIONS We present 2 cases of laryngeal trauma that were dealt with effectively so that both patients made a full recovery. It is important to act quickly to secure the airway if there are any concerns about its patency. Stable patients with no evidence of laryngeal edema can be managed conservatively. Close monitoring is essential to prevent any potential airway compromise.
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Simon EM, Summers SM. Vascular Access Complications: An Emergency Medicine Approach. Emerg Med Clin North Am 2017; 35:771-788. [PMID: 28987428 DOI: 10.1016/j.emc.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Millions of central venous and arterial catheters are placed across the United States annually as mechanisms of obtaining advanced hemodynamic monitoring and facilitating acute resuscitation. Although presumably life saving or sustaining in many circumstances, current literature identifies the preprocedural and postprocedural complications of infection, thrombosis, embolism, and iatrogenic injury as resulting in patient morbidity and mortality. Today, through the application of aseptic technique, performance of operator training, and the utilization of ultrasound, emergency physicians may limit vascular access complications and improve patient outcomes.
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Affiliation(s)
- Erica Marie Simon
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio Military Medical Center, SAMMC, MCHE-EMR, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-6200, USA.
| | - Shane Matthew Summers
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio Military Medical Center, SAMMC, MCHE-EMR, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-6200, USA
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Abstract
Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.
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7
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Mitchell J, Bogar L, Burton N. Cardiothoracic surgical emergencies in the intensive care unit. Crit Care Clin 2015; 30:499-525. [PMID: 24996607 DOI: 10.1016/j.ccc.2014.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with cardiothoracic surgical emergencies are frequently admitted to the ICU, either prior to operative intervention or after surgery. Recognition and appropriate timing of operative intervention are key factors in improving outcomes. A collaborative team approach with the cardiothoracic service is imperative in managing this patient population.
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Affiliation(s)
- Jessica Mitchell
- Department of Critical Care Medicine, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Linda Bogar
- Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA; Cardiac Vascular & Thoracic Surgery Associates, Inova Fairfax Hospital, 2921 Telestar Court, Falls Church, VA 22042, USA
| | - Nelson Burton
- Cardiac Vascular & Thoracic Surgery Associates, Inova Fairfax Hospital, 2921 Telestar Court, Falls Church, VA 22042, USA
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Gaillard J, Joines JB, Coker AC. Penetrating Aortic Injury Due to a Projectile From a Lawn Mower. J Emerg Med 2015; 49:188-91. [PMID: 25986330 DOI: 10.1016/j.jemermed.2015.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 02/07/2015] [Accepted: 02/21/2015] [Indexed: 10/23/2022]
Affiliation(s)
- John Gaillard
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Justin B Joines
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Amy C Coker
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
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Montoya J, Stawicki SP, Evans DC, Bahner DP, Sparks S, Sharpe RP, Cipolla J. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg 2015; 42:119-26. [PMID: 26038031 DOI: 10.1007/s00068-015-0512-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/03/2015] [Indexed: 01/12/2023]
Abstract
Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.
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Affiliation(s)
- J Montoya
- St Luke's Regional Level I Resource Trauma Center, Bethlehem, PA, USA
| | - S P Stawicki
- St Luke's Regional Level I Resource Trauma Center, Bethlehem, PA, USA. .,Department of Research and Innovation, St Luke's University Health Network, Bethlehem, PA, 18015, USA.
| | - D C Evans
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University College of Medicine, Columbus, OH, USA
| | - D P Bahner
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - S Sparks
- St Luke's Regional Level I Resource Trauma Center, Bethlehem, PA, USA
| | - R P Sharpe
- St Luke's Regional Level I Resource Trauma Center, Bethlehem, PA, USA
| | - J Cipolla
- St Luke's Regional Level I Resource Trauma Center, Bethlehem, PA, USA
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Abstract
Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.
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Affiliation(s)
- John J. Gallagher
- John J. Gallagher is Clinical Nurse Specialist/Trauma Program Manager, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104
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Chung JH, Cox CW, Mohammed TLH, Kirsch J, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Kanne JP, Kazerooni EA, Ketai LH, Ravenel JG, Saleh AG, Shah RD, Steiner RM, Suh RD. ACR Appropriateness Criteria Blunt Chest Trauma. J Am Coll Radiol 2014; 11:345-51. [DOI: 10.1016/j.jacr.2013.12.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
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12
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Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model. J Surg Res 2013; 184:450-7. [DOI: 10.1016/j.jss.2013.05.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 03/29/2013] [Accepted: 05/10/2013] [Indexed: 11/21/2022]
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Management of severe thoracic impalement trauma against two-wheeled horse carriage: a case report and literature review. Indian J Surg 2013; 76:297-302. [PMID: 25278654 DOI: 10.1007/s12262-013-0825-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 01/15/2013] [Indexed: 12/16/2022] Open
Abstract
Thoracic injuries in general are of great importance due to their high incidence and high mortality. Thoracic impalement injuries are rare but severe due to the combination of cause, effect and result. This study's primary objective is to report the case of a young man who was impaled by a two-wheeled horse carriage shaft while crashing his motorcycle in a rural zone. An EMT-B ferry was called at the crash scene and a conscious patient was found, sustaining a severe impalement injury to the left hemithorax, suspended over the floor by the axial skeleton with the carriage shaft coming across his left chest. As a secondary objective, a literature review of thoracic impalement injuries is performed. Cases of thoracic impalement injury require unique and individualized care based on injury severity and affected organs. Reported protocols for managing impalement injuries are entirely anecdotal, with no uniformity on impaled patient's approach and management. In penetrating trauma, it is essential not to remove the impaled object, so that possible vascular lesions remain buffered by the object, avoiding major bleeding and exsanguination haemorrhage. Severed impaled thoracic patients should be transferred to a specialist centre for trauma care, as these lesions typically require complex multidisciplinary treatment. High-energy thoracic impalement injuries are rare and hold a high mortality rate, due to the complexity of trauma and associated injuries such as thoracic wall and lung lesions. Modern medicine still seems limited in cases of such seriousness, not always with satisfactory results.
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