Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the Impact

Traumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.

Penetrating cardiac injury: a narrative review

Background and Objective

Penetrating cardiac trauma is rare but can cause life-threatening complications. Survival is dependent on prompt diagnosis and treatment. Given the low incidence and life-threatening implications, it is difficult to study in large prospective studies. The current literature regarding penetrating cardiac trauma comes primarily from large, experienced trauma centers and military sources. Understanding the history, current literature and even expert opinion can help with effectively treating injury promptly to maximize survival after penetrating cardiac trauma. We aimed to review the etiology and history of penetrating cardiac trauma. We review the prehospital treatment and initial diagnostic modalities. We review the incisional approaches to treatment including anterolateral thoracotomy, median sternotomy and subxiphoid window. The repair of atrial, ventricular and coronary injuries are also addressed in our review. The purpose of this paper is to perform a narrative review to better describe the history, etiology, presentation, and management of penetrating cardiac trauma.

Methods

A narrative review was preformed synthesizing literature from MEDLINE and bibliographic review from identified publications. Studies were included based on relevance without exclusion to time of publication or original publication language.

Key Content and Findings

Sonographic identification of pericardial fluid can aid in diagnosis of patients too unstable for CT. Anterolateral thoracotomy should be used for emergent repairs and initial stabilization. A median sternotomy can be used for more stable patients with known injuries. Carefully placed mattress sutures can be useful for repair of injuries surrounding coronary vessels to avoid devascularization.

Conclusions

Penetrating cardiac trauma is life threatening and requires prompt workup and treatment. Trauma algorithms should continue to refine and be clear on which patients should undergo an emergency department (ED) thoracotomy, median sternotomy and further imaging.

Refractory Ventricular Fibrillation in Traumatic Cardiac Arrest: A Case Report and Review of the Literature

Ventricular fibrillation (VF) is a lethal cardiac arrhythmia that leads to cardiac arrest and death. It is especially deadly when it fails to respond to conventional treatment with electrical defibrillation. This arrhythmia is often triggered by acute myocardial ischemia, but in rare cases, it can be precipitated by direct myocardial trauma. Most patients with traumatic cardiac arrest do not survive, but in a minority of patients, an emergency thoracotomy may improve survival by addressing reversible causes such as haemorrhage control, relief of cardiac tamponade, and direct wound closure. We present an unusual case of a traumatic cardiac arrest, presenting with refractory ventricular fibrillation due to a cardiac laceration in a young trauma patient with an isolated chest injury.

Penetrating Thoracic Injury and Fatal Aortic Transection From the Barb of a Stingray

Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.

Traumatic hemothorax due to chance fracture requiring emergency surgical management: A report of two cases

Traumatic hemothorax is usually caused by thoracic organ damage. Cases of atypical bleeding sources may be difficult to diagnose. Here we present two surgical cases of vertebral fracture that caused hemothorax. Case 1: an 81-year-old man was admitted to our hospital after a fall. Computed tomography showed right hemothorax without rib fractures. He suddenly developed shock and intrathoracic hemorrhage. Thoracotomy revealed the bleeding source as a transverse laceration in T7. Case 2: an 83-year-old woman fell on her back and was admitted. Computed tomography indicated an L1 vertebral fracture. A few days later, she suddenly developed a right hemothorax. An intrathoracic hemorrhage was sustained after transcatheter embolization. Thoracotomy revealed a diaphragmatic rupture. Total cross-fracture of the vertebral body solely caused the hemothorax. If bleeding source is unclear in elderly patients, this etiology should be considered. We saved both patients by performing spinal fusion surgery at the appropriate time.

Less is more: lung-sparing direct repair of a traumatic rupture of the bronchus intermedius

Major trauma is one of the most common causes of death in the western world in the young population (15-25 years). Thoracic trauma represents 25% of traumatic deaths, and the incidence of tracheobronchial injuries in literature is lower than 5%. Nevertheless, airway injuries are life-threatening conditions. Here we present a case of a 25-year-old patient who underwent a severe motorcycle crash. The injury severity score (ISS) was 35 at admission to the hospital. A right middle bronchus laceration <2 cm involving the whole thickness of the wall of the bronchus intermedius was identified. An urgent right posterolateral thoracotomy was performed, and the lesion was directly repaired. A conservative intervention was the key to grant our patient a healthy life.

Large thoracic defect due to shotgun violation - surgical emergency management

Shotgun injuries from a short distance (<3 m) may cause massive bleeding and tissue destruction. Only immediate aggressive (surgical) therapy prevents lethal outcome.

We report about a 27-year-old patient, who was wounded on the left chest wall by a straight-cut shotgun from a short distance. In cases of this special traumatic pattern damage control measures are necessary. The measures should take place in preclinical emergency management (by the on-site emergency physician).

We report about the emergency management from admission to our hospital and the following surgical treatment until discharge from the hospital.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.