Early Management of Retained Hemothorax in Blunt Head and Chest Trauma

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma Background Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. Materials and methods From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. Result All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were dis- charged (11.74 vs. 14.10, p\ 0.05). Discussion In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma. Yi-Pin Chou and Tzu-Chin Wu have contributed equally to this work and are equally considered to be corresponding author. & Yi-Pin Chou Department of Cosmetic Science, College of Human chou2763e@yahoo.com.tw Ecology, Chang Gung University of Science and Technology, & Tzu-Chin Wu Kweishan, Taoyuan, Taiwan wuziching88@yahoo.com.tw Division of Chest Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Division of Trauma, Department of Emergency, Kaohsiung Taichung, Taiwan Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung City 813, Taiwan School of Medicine, Chung Shan Medical University, Taichung, Taiwan Department of Kinesiology, Health, and Leisure Studies, National University of Kaohsiung, Kaohsiung City, Taiwan 123 2062 World J Surg (2018) 42:2061–2066 Introduction Materials and methods In Taiwan, blunt injury is the main type of trauma resulting Setting and patients from traffic accidents. It usually causes injuries to many different regions of the human body. Head and chest This observational study was conducted in a level I trauma injuries usually occur together [1–3]. Managing such medical center in Southern Taiwan with 1300 beds serving multiple traumas is always a great challenge; exact about 1200 trauma visits per month. During the study assessments and lifesaving procedures are mandated and period, all patients admitted from our emergency depart- should be performed rapidly. However, many surgical ment (ED) with major trauma with both blunt head and interventions should be delayed due to head injury because thoracic injuries were included. All patients’ data included damaged brain tissue requires longer time periods of demographics, the mechanism of injury, the number of ribs observation to maintain adequate oxygenation and perfu- fractured, associated injuries, Injury Severity Score (ISS), sion [1, 2, 4]. Glasgow Coma Scale (GCS) at the emergency department Most major blunt chest traumas involve rib fracture with and discharge, concomitant chest injuries, pulmonary lung contusion and hemopneumothorax. About 85 % of contusion scores, postoperative complications, acute res- patients could be treated with pain control or simple tube piratory failure, number of ventilator days, length of stay thoracostomies even with head injury [5, 6]. Some patients (LOS) in the intensive care unit (ICU), and hospital LOS will develop retained pleural collections that should be were prospectively collected with a standard form. A senior managed with further surgical intervention to prevent post- trauma surgeon reviewed all the data for accuracy. The traumatic complications [6–8]. Since 1990, video-assisted ethics committee of the study hospital approved the study. thoracoscopic surgery (VATS) has become a popular and Patients older than 14 years of age admitted to the acceptable method for treating retained hemothorax trauma unit in this hospital with blunt head and chest [5, 9–11]. Although early VATS that could improve clin- trauma were included. All trauma patients received com- ical outcomes has been proofed in many studies, timing of puted tomography (CT) of the brain and chest, and those these operations is usually influenced by associated inju- who had hemothorax or pneumothorax were treated with a ries, especially the head injury. Due to the autoregulation 32F straight thoracostomy tube during initial evaluation at of cerebral vascularity recovered at least 96 h after brain the ED with low-negative pressure (-15cmH O). After injuries [1, 2, 4], VATS is usually delayed until the detailed evaluations, all of these patients were admitted patients’ head injuries stabilized somewhat after 4 days. into the intensive care unit (ICU). Chest roentgenograms The effects of time periods to VATS in patients with were routinely followed up daily. The chest tubes were both blunt head and chest trauma have rarely been studied. adjusted when infiltration of routine chest x-ray is found. A hypothesis is set up in this study that early interventions Bronchoscopy for sputum suction was also applied when may not worsen the brain condition but rather will improve atelectasis of lung was suspected. All of these patients final clinical outcomes. A new strategy of early manage- received a brain CT and chest CT again at 24 to 48 h after ment of thoracic injury with head injury is proposed. The trauma to evaluate the condition of intracranial hemorrhage outcomes of the two groups of major blunt injury patients and the volume of pleural collection [12]. Patients whose with head injury who received early VATS within 4 days secondary chest CT showed a retained pleural collection and those whose treatment was delayed for more than persisting at more than 300 ml were considered for VATS. 4 days are compared. The retained hemothorax is calculated by formula V (in mL) = d 9 X 9 L, where d is the greatest depth of hemothorax from the chest wall to the lung on any CT image in centimeters, and L is the craniocaudal length in centimeters multiplied by the number of slices X centimeter thickness of CT cuts [13]. The thoracic surgeons were in charge of the VATS operations with the same criteria and surgical techniques used on every patient. In this study, moderate to severe injuries to the abdomen Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung City, and limbs with an Abbreviated Injury Score (AIS) over Taiwan three were excluded. Patients with severe head injury with Department of Optometry, Shu-Zen Junior College of a mass effect for which an emergent craniotomy should be Medicine and Management, Kaohsiung, Taiwan performed immediately were also excluded. Patients who Department of Nursing, Kaomei Junior College of Health were hemodynamically unstable, had more than 1500 mL Care and Management, Kaohsiung, Taiwan 123 World J Surg (2018) 42:2061–2066 2063 of blood on placement of the initial tube thoracostomy, or Results had ongoing blood loss of more than 250 mL/h and had received an emergency thoracotomy were not included. From May 2005 to February 2012, a total of 2023 patients Patients with blunt aortic injury were also excluded, as with chest injuries were admitted to our hospital. Sixty-one were patients with severe medical disease including patients had moderate to severe head injury with intracra- chronic heart failure, end-stage renal disease, severe liver nial hemorrhage without indication of emergent cran- cirrhosis, and chronic obstructive pulmonary disease. iotomy. They also had blunt chest injuries with Time periods from trauma to VATS performance were complicated hemothorax or pneumothorax or both. All of variable in these patients. According to study of Yokobori these patients received thoracoscopic drainage because of et al. [4], these procedures are usually delayed, being clotted post-traumatic hemothorax after tube thoracos- performed more than 4 days after trauma for brain tomies at the ED. Table 1 displays these patients’ charac- autoregulation recovery. In this study, some patients teristics. There were 45 men and 16 women, their ages received VATS within 4 days after injury. For example, if ranging from 16 to 87 years (mean ± SD, a patient had a limb fracture needing fixation or a huge 51.61 ± 18.82 years). The injury mechanisms were crush wound requiring debridement within short time after motorcycle-related injury in 46 patients, car driver or trauma, VATS would be arranged with these associate passenger injury in four patients, fall-related injuries in surgeries at the same time. Therefore, patients were divided four patients, and bicycle rider or pedestrian injuries in into two groups based on the day of VATS performance: seven patients. Their mean Injury Severity Scores (ISS) Group 1, within 4 days; Group 2, 5 or more days. were 25.46 ± 6.00. In this study, all the patients with head injury were The AIS of the patients’ thoracic region was observed without surgical intervention and received VATS 3.23 ± 0.53. The AIS of the head was 3.25 ± 0.51. Fifty- due to retained hemothorax. The VATS was performed in two patients had subarachnoid hemorrhage with intracere- the operating room under general anesthesia. Routine one bral hemorrhage, six patients had subdural hemorrhage, dose of prophylactic antibiotics was given at the beginning and three patients had small epidural hemorrhage. There of VATS. Evacuations of retained pleural collections were were no surgical indications for head injuries in these performed via VATS procedures. The pleural effusions patients. The Glasgow Coma Scale (GCS) at initial were sent for microbial cultures during VATS in both groups. Finally, each patient was transferred to trauma ICU Table 1 Demographic analysis of patients treated with VATS for for further postoperative care. After either procedure, the blunt trauma (n = 61) thoracostomy tubes were connected to suction with low- Mean age ± SD (year) 51.61 ± 18.82 negative pressure (-15cmH O) and were removed at the % Males 73.8% discretion of the thoracic surgeons when drainage was less Median ISS 25.46 ± 6.00 than 100 mL/24 h and no air leaks were present [14]. Mechanism of injury Post-trauma infection included positive microbial cul- Motorcyclist or passenger 46 tures of sputum, pleural effusion, and blood. Postoperative Car driver or passenger 4 outcomes were in-hospital mortality, length of ventilator Fall 4 use, coma scale, and ICU and hospital LOS. Bicycle rider or pedestrian 7 Mortality (none related to VATS) 4.9% (3/61) Statistical analysis Associated injuries % Abdominal injury 34.4%(21/61) An initial descriptive analysis was performed for every % Extremity injury 75.4%(46/61) variable, determining frequencies and averages in the two Anatomic injury score of thoracic injury 3.23 ± 0.53 groups. Numerical variables were presented as Anatomic injury score of head injury 3.25 ± 0.51 mean ± SD. Chi-square or Fisher’s test was used to eval- Pulmonary contusion score 6.44 ± 1.8 uate categorical or proportional variables between the groups. Continuous variables between the groups were GCS at ED 11.74 ± 3.26 GCS at discharge 14.10 ± 2.78 compared by analysis of variance. Statistical significant is considered as p\ 0.05. All data were analyzed using the Time from trauma to VATS (mean ± SD) 5.78 ± 3.22 SPSS 18.0 statistical software. The power of ICU length of ICU LOS (days) 13.38 ± 16.15 stay was 0.84, with sample size 61, Type I error rate (a) In-hospital LOS (days) 28.00 ± 19.66 5%, and sampling ratio = 1. ISS Injury Severity Score, VATS video-assisted thoracoscopy, GCS Glasgow Coma Scale, ED emergency department, ICU intensive care unit, LOS length of stay 123 2064 World J Surg (2018) 42:2061–2066 assessment was 11.74 ± 3.26. When patients were dis- 61.3%, p = 0.714). Therefore, the two groups of patients charged, the mean GCS returned to 14.10 ± 2.78 (paired were statistically comparable and analogous. t test, p\ 0.05, excluding the expired patients). Patient The AIS of limbs was higher in Group 1, with statistical mortality was 4.9% (3/61). The pulmonary contusion significance (1.87 ± 1.23 vs. 1.23 ± 0.92, p = 0.012). scores were calculated after an initial chest CT was The ISS of Group 2 was slightly lower than that of Group obtained. The mean values were 6.44 ± 1.88. Thirty-six 1, but there was no statistical clinical significance between patients (36/61, 59.0%) had acute respiratory failure that the two groups (25.47 ± 5.61, and 25.45 ± 6.45, needed endotracheal tube intubation with a ventilator for p = 0.992, respectively). Positive enterobacteria cultures respiratory support within 24 h after trauma. The mean from sputum in the two groups also showed no significant time between the trauma and the performance of the VATS difference (13.3 vs. 9.7%, p = 0.654). was 6 days (5.77 ± 3.22). The mean (± SD) of ICU and Table 3 shows the outcomes between the two groups. hospital LOSs were 13.38 (±16.15) and 28.00 (±19.66) The ICU LOS and hospital LOS were both longer in Group days. 2(p \ 0.05, respectively). The total periods of ventilator In this study, all patients had tube thoracostomy before use days were also longer in Group 2 (p = 0.016). The VATS. No VATS procedure was converted to thoracotomy length of post-VATS ventilator use was longer in Group 2 during the surgical intervention. In order to realize the (5.00 ± 7.39 and 11.33 ± 18.77, p = 0.079, respectively). benefits of early VATS drainage for retained hemothorax The time interval of chest tube usage after VATS showed in patients with combined head injuries, patients were no statistical difference between the two groups divided into two groups according to the time from trauma (9.00 ± 4.59 and 9.52 ± 10.36, p = 0.802). The total time to VATS performance. Group 1 patients received VATS periods of chest tube insertion were shorter in Group 1 than within 4 days (mean 3.12 ± 0.49 days). Group 2 patients in Group 2 (11.7 ± 5.37 and 16.38 ± 10.76, p = 0.036). received surgery after more than 4 days (mean Rate of pleural infections was increased in Group 2 (6.7 vs. 8.35 ± 2.56 days). Patients in both groups received once 29.0%, p = 0.043). VATS during their in-hospital course. Table 2 displays the results of the basic demographic comparisons between the two groups. The basic demographics, including age, gen- Discussion der, mechanism of injury, number of ribs fractured, pul- monary contusion scores, and AIS of head and chest and Head and chest injuries frequently occur together in blunt abdomen, showed no statistical differences between the trauma [15, 16]. In multiple injuries, maintaining groups. The rate of acute respiratory failure was not sig- stable neurological status is the first priority. Thus, the nificantly different between the two groups (56.7 vs. timing of urgent surgical interventions will be delayed when a patient has a head injury. However, many recent Table 2 Comparison of basic demographics between patient groups Group 1 (n = 30) Group 2 (n = 31) p Age (mean ± SD) 48.00 ± 16.49 55.06 ± 20.49 0.146 Gender (male) 21 (70.4%) 24 (77.4%) 0.510 ISS 25.47 ± 5.61 25.45 ± 6.45 0.992 Mechanism of injury 0.988 Motorcycle 23 23 Car 2 2 Fall 2 2 Walk or bicycle 3 4 Number of ribs fractured 5.73 ± 3.86 6.00 ± 3.34 0.774 Pulmonary contusion scores 6.50 ± 1.83 6.39 ± 1.96 0.817 Thoracic AIS 3.13 ± 0.43 3.32 ± 0.60 0.163 Head AIS 3.20 ± 0.48 3.29 ± 0.53 0.489 GCS at ED 11.67 ± 3.69 11.81 ± 2.86 0.869 GCS at discharge 14.10 ± 2.52 14.10 ± 3.05 0.869 Acute respiratory failure in 24 h 17 (56.7%) 19 (61.3%) 0.714 ISS Injury Severity Score, AIS anatomic injury score 123 World J Surg (2018) 42:2061–2066 2065 Table 3 Comparison of clinical outcomes between patient groups Group 1 (n = 30) Group 2 (n = 31) p ICU LOS 8.97 ± 6.49 17.65 ± 21.03 0.035 Hospital LOS 20.63 ± 9.08 35.13 ± 24.21 0.003 Total ventilator days 6.77 ± 7.31 18.55 ± 24.94 0.016 Post-VATS ventilator days 5.00 ± 7.39 11.33 ± 18.77 0.079 Chest tube use days 11.70 ± 5.37 16.38 ± 10.77 0.037 Post-VATS chest tube use days 9.00 ± 4.59 9.51 ± 10.36 0.802 Positive microbial cultures Sputum 10 (33.3%) 16 (51.6%) 0.198 Pleural effusion 2 (6.7%) 9 (29.0%) 0.043 reports suggest that early evacuation of the pleural col- The basic demographic data were the same in each lection within 4–5 days after trauma could achieve better group in this study. The greatest difference between these clinical outcomes [10, 15, 16]. In this study, early surgical two groups was found in limb injuries. All patients in intervention in chest injury really could obtain a better Group 1 had limb injuries, such as open fractures or neu- outcome in patients with stable head injury. rovascular injuries, requiring early damage control inter- Acute respiratory failure is prone to induce post-trau- vention. During these surgeries, VATS was performed matic infections [8, 14]. These two complications are the simultaneously for retained pleural collections. In most main reasons for prolonging the in-hospital course. These cases, the surgical time of VATS was less than 30 min, complications occur with high frequency in the case of without any increase in the total surgical periods. combined head and chest injuries. In this study, half of the In this study, time periods of ventilator and chest tube patients (36/61, 59.0%) required emergent endotracheal use after VATS were collected to evaluate the successful tube intubation because of a change of consciousness or a rates of VATS between the two groups. The total time rapid decrease in oxygen saturation. The rate of acute periods of ventilator and chest tube usage were both longer respiratory failure was equal in the two groups. Many in Group 2, but the postoperative time periods were the studies have proofed that shorting the periods of ventilator same in the two groups, signifying that VATS was per- dependent could also decrease the rate of pneumonia. In formed with same efficacy in both groups. The longer total this study, there were 26 patients who had post-traumatic time periods in Group 2 resulted from the longer waiting pneumonia that were derived from aspiration pneumonia time for monitoring the neurological condition. In this and nosocomial pneumonia. The rate of enterobacterial study, the VATS could be performed safely within 4 days cultures from sputum was similar in each group. It means or less. All patients’ GCS scores were improved when they that rate of aspiratory pneumonia was also equal in each were discharged, and the GCS at discharge showed no group. In Group 1, early VATS could re-expand the lung difference between the two groups, signifying that the early parenchyma earlier that could restore the lung function surgical procedure did not influence these patients’ brain more rapidly. By decreasing the ventilator dependent condition. The routine waiting time of at least 4 days in periods, the rate of nosocomial pneumonia may also be head injury patients without indication of emergency decreased indirectly. craniotomy may be unnecessary. The rate of positive microbial cultures from pleural Due to advancement of ICU care, the mortality of severe effusion obtained during VATS was much lower in Group and multiple trauma patients is much lower than before 1 with statistical difference. It means that early VATS in [2, 16, 17]. In this study, only three patients expired: the Group 1 could remove retained hemothorax more early to mortality rate was 4.9% (3/61). One patient in Group 1 had prevent further pleural infections. That is, the retained progressively scattered intracranial hemorrhage and hemothorax had been infected with bacteria in most Group unfortunately expired due to central failure. The other two 2 patients. The antibiotics treatment course in these in Group 2 had severe pneumonia-induced septic shock patients will be lengthened. Due to the early control of that induced multiple-organ failure. The other patients all infection in Group 1, the antibiotic requirements and cost recovered after comprehensive care in the ICU. Therefore, were both decreased. This also made it easier to gradually under detail monitoring and treatments, VATS could be discontinue the ventilator use. These advantageous effects performed earlier in patients whose brain condition is rel- played an important role in shortening the whole hospital atively stable. course. 123 2066 World J Surg (2018) 42:2061–2066 This is the first study to observe the early VATS inter- References vention in chest trauma with brain injury. However, this 1. Brain Trauma Foundation, American Association of Neurological study has several limitations. First, the case numbers in this Surgeons, Congress of Neurological Surgeons (2007) Guidelines study were low. Only 61 patients who qualified for the for the management of severe traumatic brain injury. J Neuro- inclusion criteria during the study period were enrolled. It trauma 24(Suppl 1):S1–106 was difficult to find qualifying patients because only 10% 2. Robertson CS, Valadka AB, Hannay HJ et al (1999) Prevention of secondary ischemic insults after severe head injury. Crit Care of chest blunt trauma cases exhibit retained pleural col- Med 27(2086–209):5 lections, and also because cases of severe head injuries 3. Kalb DC, Ney AL, Rodriguez JL et al (1998) Assessment of the with emergent craniotomy were excluded. However, the relationship between timing of fixation of the fracture and sec- preoperative status and demographic matching of the two ondary brain injury in patients with multiple trauma. Surgery 124:739–744 (discussion 744–735) groups decrease the bias, and the power of this study is 4. Yokobori S, Watanabe A, Matsumoto G et al (2011) Time course 0.84; therefore, fewer case numbers may not influence the of recovery from cerebral vulnerability after severe traumatic accuracy of the statistical analysis. Second, although this brain injury: a microdialysis study. J Trauma 71:1235–1240 study was based on prospective data collection, some of the 5. Heniford BT, Carrillo EH, Spain DA et al (1997) The role of thoracoscopy in the management of retained thoracic collections parameters were collected from chart reviews. Errors may after trauma. Ann Thorac Surg 63(940–94):3 have occurred during recording. To prevent this bias, a 6. Helling TS, Gyles NR 3rd, Eisenstein CL et al (1989) Compli- senior trauma surgeon supervised a rechecking of the exact cations following blunt and penetrating injuries in 216 victims of data. Third, many factors could influence the duration of chest trauma requiring tube thoracostomy. J Trauma 29:1367–1370 acute respiratory failure. Severe abdominal injury could 7. Eddy AC, Luna GK, Copass M (1989) Empyema thoracis in lengthen the in-hospital stay. Chronic medical problems patients undergoing emergent closed tube thoracostomy for tho- such as chronic obstructive pulmonary disease, liver cir- racic trauma. Am J Surg 157(494–49):7 rhosis and chronic heart failure could also increase mor- 8. Richardson JD, Carrillo E (1997) Thoracic infection after trauma. Chest Surg Clin N Am 7(401–42):7 bidity and mortality. All of these biases were excluded 9. Meyer DM, Jessen ME, Wait MA et al (1997) Early evacuation of from enrollment in this study. In addition, aspiration traumatic retained hemothoraces using thoracoscopy: a prospec- pneumonia is another complication after trauma, especially tive, randomized trial. Ann Thorac Surg 64:1396–1400 (discus- for head injury with unconscious status [18]. If the rate of sion 1400–1391) 10. Carrillo EH, Richardson JD (2005) Thoracoscopy for the acutely positive culture from enterobacteria was the same in these injured patient. Am J Surg 190(234–23):8 two groups, this bias would therefore also be decreased. 11. McManus K, McGuigan J (1994) Minimally invasive therapy in Finally in recent studies, thrombolytic agents provide thoracic injury. Injury 25(609–61):4 another choice for treating retained hemothorax [19]. 12. Dennis BM, Gondek SP, Guyer RA et al (2017) Use of an evi- dence-based algorithm for patients with traumatic hemothorax Patients who are not candidates for VATS, intra-pleural reduces need for additional interventions. J Trauma Acute Care irrigation with thrombolytic agents may also be considered. Surg 82(728–73):2 13. Mergo PJ, Helmberger T, Didovic J et al (1999) New formula for quantification of pleural effusions from computed tomography. J Thorac Imaging 14(122–12):5 Conclusion 14. Chou YP, Lin HL, Wu TC (2015) Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin In patients with a combination of chest and head injuries Pulm Med 21(393–39):8 without indication of emergency craniotomy, earlier VATS 15. Morales Uribe CH, Villegas Lanau MI, Petro Sanchez RD (2008) Best timing for thoracoscopic evacuation of retained post-trau- could be performed safely to obtain better clinical matic hemothorax. Surg Endosc 22(91–9):5 outcomes. 16. Smith JW, Franklin GA, Harbrecht BG et al (2011) Early VATS for blunt chest trauma: a management technique underutilized by Compliance with ethical standards acute care surgeons. J Trauma 71:102–105 (discussion 105–107) 17. Tuttle MS, Smith WR, Williams AE et al (2009) Safety and Conflict of interest All the authors have no conflict of interest of any efficacy of damage control external fixation versus early defini- financial and personal relationships with other people, or organiza- tive stabilization for femoral shaft fractures in the multiple-in- tions in relation to this study. jured patient. J Trauma 67(602–60):5 18. Lin HL, Huang WY, Yang C et al (2014) How early should Open Access This article is distributed under the terms of the VATS be performed for retained haemothorax in blunt chest Creative Commons Attribution 4.0 International License (http://crea trauma? Injury 45:1359–1364 tivecommons.org/licenses/by/4.0/), which permits unrestricted use, 19. Kumar S, Rathi V, Rattan A et al (2015) VATS versus distribution, and reproduction in any medium, provided you give intrapleural streptokinase: a prospective, randomized, controlled appropriate credit to the original author(s) and the source, provide a clinical trial for optimum treatment of post-traumatic Residual link to the Creative Commons license, and indicate if changes were Hemothorax. Injury 46:1749–1752 made. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png World Journal of Surgery Springer Journals

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma

Free
6 pages

Loading next page...
 
/lp/springer_journal/early-management-of-retained-hemothorax-in-blunt-head-and-chest-trauma-aiK18s3YfZ
Publisher
Springer Journals
Copyright
Copyright © 2018 by The Author(s)
Subject
Medicine & Public Health; Surgery; Abdominal Surgery; Cardiac Surgery; General Surgery; Thoracic Surgery; Vascular Surgery
ISSN
0364-2313
eISSN
1432-2323
D.O.I.
10.1007/s00268-017-4420-x
Publisher site
See Article on Publisher Site

Abstract

Background Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. Materials and methods From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. Result All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were dis- charged (11.74 vs. 14.10, p\ 0.05). Discussion In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma. Yi-Pin Chou and Tzu-Chin Wu have contributed equally to this work and are equally considered to be corresponding author. & Yi-Pin Chou Department of Cosmetic Science, College of Human chou2763e@yahoo.com.tw Ecology, Chang Gung University of Science and Technology, & Tzu-Chin Wu Kweishan, Taoyuan, Taiwan wuziching88@yahoo.com.tw Division of Chest Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Division of Trauma, Department of Emergency, Kaohsiung Taichung, Taiwan Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung City 813, Taiwan School of Medicine, Chung Shan Medical University, Taichung, Taiwan Department of Kinesiology, Health, and Leisure Studies, National University of Kaohsiung, Kaohsiung City, Taiwan 123 2062 World J Surg (2018) 42:2061–2066 Introduction Materials and methods In Taiwan, blunt injury is the main type of trauma resulting Setting and patients from traffic accidents. It usually causes injuries to many different regions of the human body. Head and chest This observational study was conducted in a level I trauma injuries usually occur together [1–3]. Managing such medical center in Southern Taiwan with 1300 beds serving multiple traumas is always a great challenge; exact about 1200 trauma visits per month. During the study assessments and lifesaving procedures are mandated and period, all patients admitted from our emergency depart- should be performed rapidly. However, many surgical ment (ED) with major trauma with both blunt head and interventions should be delayed due to head injury because thoracic injuries were included. All patients’ data included damaged brain tissue requires longer time periods of demographics, the mechanism of injury, the number of ribs observation to maintain adequate oxygenation and perfu- fractured, associated injuries, Injury Severity Score (ISS), sion [1, 2, 4]. Glasgow Coma Scale (GCS) at the emergency department Most major blunt chest traumas involve rib fracture with and discharge, concomitant chest injuries, pulmonary lung contusion and hemopneumothorax. About 85 % of contusion scores, postoperative complications, acute res- patients could be treated with pain control or simple tube piratory failure, number of ventilator days, length of stay thoracostomies even with head injury [5, 6]. Some patients (LOS) in the intensive care unit (ICU), and hospital LOS will develop retained pleural collections that should be were prospectively collected with a standard form. A senior managed with further surgical intervention to prevent post- trauma surgeon reviewed all the data for accuracy. The traumatic complications [6–8]. Since 1990, video-assisted ethics committee of the study hospital approved the study. thoracoscopic surgery (VATS) has become a popular and Patients older than 14 years of age admitted to the acceptable method for treating retained hemothorax trauma unit in this hospital with blunt head and chest [5, 9–11]. Although early VATS that could improve clin- trauma were included. All trauma patients received com- ical outcomes has been proofed in many studies, timing of puted tomography (CT) of the brain and chest, and those these operations is usually influenced by associated inju- who had hemothorax or pneumothorax were treated with a ries, especially the head injury. Due to the autoregulation 32F straight thoracostomy tube during initial evaluation at of cerebral vascularity recovered at least 96 h after brain the ED with low-negative pressure (-15cmH O). After injuries [1, 2, 4], VATS is usually delayed until the detailed evaluations, all of these patients were admitted patients’ head injuries stabilized somewhat after 4 days. into the intensive care unit (ICU). Chest roentgenograms The effects of time periods to VATS in patients with were routinely followed up daily. The chest tubes were both blunt head and chest trauma have rarely been studied. adjusted when infiltration of routine chest x-ray is found. A hypothesis is set up in this study that early interventions Bronchoscopy for sputum suction was also applied when may not worsen the brain condition but rather will improve atelectasis of lung was suspected. All of these patients final clinical outcomes. A new strategy of early manage- received a brain CT and chest CT again at 24 to 48 h after ment of thoracic injury with head injury is proposed. The trauma to evaluate the condition of intracranial hemorrhage outcomes of the two groups of major blunt injury patients and the volume of pleural collection [12]. Patients whose with head injury who received early VATS within 4 days secondary chest CT showed a retained pleural collection and those whose treatment was delayed for more than persisting at more than 300 ml were considered for VATS. 4 days are compared. The retained hemothorax is calculated by formula V (in mL) = d 9 X 9 L, where d is the greatest depth of hemothorax from the chest wall to the lung on any CT image in centimeters, and L is the craniocaudal length in centimeters multiplied by the number of slices X centimeter thickness of CT cuts [13]. The thoracic surgeons were in charge of the VATS operations with the same criteria and surgical techniques used on every patient. In this study, moderate to severe injuries to the abdomen Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung City, and limbs with an Abbreviated Injury Score (AIS) over Taiwan three were excluded. Patients with severe head injury with Department of Optometry, Shu-Zen Junior College of a mass effect for which an emergent craniotomy should be Medicine and Management, Kaohsiung, Taiwan performed immediately were also excluded. Patients who Department of Nursing, Kaomei Junior College of Health were hemodynamically unstable, had more than 1500 mL Care and Management, Kaohsiung, Taiwan 123 World J Surg (2018) 42:2061–2066 2063 of blood on placement of the initial tube thoracostomy, or Results had ongoing blood loss of more than 250 mL/h and had received an emergency thoracotomy were not included. From May 2005 to February 2012, a total of 2023 patients Patients with blunt aortic injury were also excluded, as with chest injuries were admitted to our hospital. Sixty-one were patients with severe medical disease including patients had moderate to severe head injury with intracra- chronic heart failure, end-stage renal disease, severe liver nial hemorrhage without indication of emergent cran- cirrhosis, and chronic obstructive pulmonary disease. iotomy. They also had blunt chest injuries with Time periods from trauma to VATS performance were complicated hemothorax or pneumothorax or both. All of variable in these patients. According to study of Yokobori these patients received thoracoscopic drainage because of et al. [4], these procedures are usually delayed, being clotted post-traumatic hemothorax after tube thoracos- performed more than 4 days after trauma for brain tomies at the ED. Table 1 displays these patients’ charac- autoregulation recovery. In this study, some patients teristics. There were 45 men and 16 women, their ages received VATS within 4 days after injury. For example, if ranging from 16 to 87 years (mean ± SD, a patient had a limb fracture needing fixation or a huge 51.61 ± 18.82 years). The injury mechanisms were crush wound requiring debridement within short time after motorcycle-related injury in 46 patients, car driver or trauma, VATS would be arranged with these associate passenger injury in four patients, fall-related injuries in surgeries at the same time. Therefore, patients were divided four patients, and bicycle rider or pedestrian injuries in into two groups based on the day of VATS performance: seven patients. Their mean Injury Severity Scores (ISS) Group 1, within 4 days; Group 2, 5 or more days. were 25.46 ± 6.00. In this study, all the patients with head injury were The AIS of the patients’ thoracic region was observed without surgical intervention and received VATS 3.23 ± 0.53. The AIS of the head was 3.25 ± 0.51. Fifty- due to retained hemothorax. The VATS was performed in two patients had subarachnoid hemorrhage with intracere- the operating room under general anesthesia. Routine one bral hemorrhage, six patients had subdural hemorrhage, dose of prophylactic antibiotics was given at the beginning and three patients had small epidural hemorrhage. There of VATS. Evacuations of retained pleural collections were were no surgical indications for head injuries in these performed via VATS procedures. The pleural effusions patients. The Glasgow Coma Scale (GCS) at initial were sent for microbial cultures during VATS in both groups. Finally, each patient was transferred to trauma ICU Table 1 Demographic analysis of patients treated with VATS for for further postoperative care. After either procedure, the blunt trauma (n = 61) thoracostomy tubes were connected to suction with low- Mean age ± SD (year) 51.61 ± 18.82 negative pressure (-15cmH O) and were removed at the % Males 73.8% discretion of the thoracic surgeons when drainage was less Median ISS 25.46 ± 6.00 than 100 mL/24 h and no air leaks were present [14]. Mechanism of injury Post-trauma infection included positive microbial cul- Motorcyclist or passenger 46 tures of sputum, pleural effusion, and blood. Postoperative Car driver or passenger 4 outcomes were in-hospital mortality, length of ventilator Fall 4 use, coma scale, and ICU and hospital LOS. Bicycle rider or pedestrian 7 Mortality (none related to VATS) 4.9% (3/61) Statistical analysis Associated injuries % Abdominal injury 34.4%(21/61) An initial descriptive analysis was performed for every % Extremity injury 75.4%(46/61) variable, determining frequencies and averages in the two Anatomic injury score of thoracic injury 3.23 ± 0.53 groups. Numerical variables were presented as Anatomic injury score of head injury 3.25 ± 0.51 mean ± SD. Chi-square or Fisher’s test was used to eval- Pulmonary contusion score 6.44 ± 1.8 uate categorical or proportional variables between the groups. Continuous variables between the groups were GCS at ED 11.74 ± 3.26 GCS at discharge 14.10 ± 2.78 compared by analysis of variance. Statistical significant is considered as p\ 0.05. All data were analyzed using the Time from trauma to VATS (mean ± SD) 5.78 ± 3.22 SPSS 18.0 statistical software. The power of ICU length of ICU LOS (days) 13.38 ± 16.15 stay was 0.84, with sample size 61, Type I error rate (a) In-hospital LOS (days) 28.00 ± 19.66 5%, and sampling ratio = 1. ISS Injury Severity Score, VATS video-assisted thoracoscopy, GCS Glasgow Coma Scale, ED emergency department, ICU intensive care unit, LOS length of stay 123 2064 World J Surg (2018) 42:2061–2066 assessment was 11.74 ± 3.26. When patients were dis- 61.3%, p = 0.714). Therefore, the two groups of patients charged, the mean GCS returned to 14.10 ± 2.78 (paired were statistically comparable and analogous. t test, p\ 0.05, excluding the expired patients). Patient The AIS of limbs was higher in Group 1, with statistical mortality was 4.9% (3/61). The pulmonary contusion significance (1.87 ± 1.23 vs. 1.23 ± 0.92, p = 0.012). scores were calculated after an initial chest CT was The ISS of Group 2 was slightly lower than that of Group obtained. The mean values were 6.44 ± 1.88. Thirty-six 1, but there was no statistical clinical significance between patients (36/61, 59.0%) had acute respiratory failure that the two groups (25.47 ± 5.61, and 25.45 ± 6.45, needed endotracheal tube intubation with a ventilator for p = 0.992, respectively). Positive enterobacteria cultures respiratory support within 24 h after trauma. The mean from sputum in the two groups also showed no significant time between the trauma and the performance of the VATS difference (13.3 vs. 9.7%, p = 0.654). was 6 days (5.77 ± 3.22). The mean (± SD) of ICU and Table 3 shows the outcomes between the two groups. hospital LOSs were 13.38 (±16.15) and 28.00 (±19.66) The ICU LOS and hospital LOS were both longer in Group days. 2(p \ 0.05, respectively). The total periods of ventilator In this study, all patients had tube thoracostomy before use days were also longer in Group 2 (p = 0.016). The VATS. No VATS procedure was converted to thoracotomy length of post-VATS ventilator use was longer in Group 2 during the surgical intervention. In order to realize the (5.00 ± 7.39 and 11.33 ± 18.77, p = 0.079, respectively). benefits of early VATS drainage for retained hemothorax The time interval of chest tube usage after VATS showed in patients with combined head injuries, patients were no statistical difference between the two groups divided into two groups according to the time from trauma (9.00 ± 4.59 and 9.52 ± 10.36, p = 0.802). The total time to VATS performance. Group 1 patients received VATS periods of chest tube insertion were shorter in Group 1 than within 4 days (mean 3.12 ± 0.49 days). Group 2 patients in Group 2 (11.7 ± 5.37 and 16.38 ± 10.76, p = 0.036). received surgery after more than 4 days (mean Rate of pleural infections was increased in Group 2 (6.7 vs. 8.35 ± 2.56 days). Patients in both groups received once 29.0%, p = 0.043). VATS during their in-hospital course. Table 2 displays the results of the basic demographic comparisons between the two groups. The basic demographics, including age, gen- Discussion der, mechanism of injury, number of ribs fractured, pul- monary contusion scores, and AIS of head and chest and Head and chest injuries frequently occur together in blunt abdomen, showed no statistical differences between the trauma [15, 16]. In multiple injuries, maintaining groups. The rate of acute respiratory failure was not sig- stable neurological status is the first priority. Thus, the nificantly different between the two groups (56.7 vs. timing of urgent surgical interventions will be delayed when a patient has a head injury. However, many recent Table 2 Comparison of basic demographics between patient groups Group 1 (n = 30) Group 2 (n = 31) p Age (mean ± SD) 48.00 ± 16.49 55.06 ± 20.49 0.146 Gender (male) 21 (70.4%) 24 (77.4%) 0.510 ISS 25.47 ± 5.61 25.45 ± 6.45 0.992 Mechanism of injury 0.988 Motorcycle 23 23 Car 2 2 Fall 2 2 Walk or bicycle 3 4 Number of ribs fractured 5.73 ± 3.86 6.00 ± 3.34 0.774 Pulmonary contusion scores 6.50 ± 1.83 6.39 ± 1.96 0.817 Thoracic AIS 3.13 ± 0.43 3.32 ± 0.60 0.163 Head AIS 3.20 ± 0.48 3.29 ± 0.53 0.489 GCS at ED 11.67 ± 3.69 11.81 ± 2.86 0.869 GCS at discharge 14.10 ± 2.52 14.10 ± 3.05 0.869 Acute respiratory failure in 24 h 17 (56.7%) 19 (61.3%) 0.714 ISS Injury Severity Score, AIS anatomic injury score 123 World J Surg (2018) 42:2061–2066 2065 Table 3 Comparison of clinical outcomes between patient groups Group 1 (n = 30) Group 2 (n = 31) p ICU LOS 8.97 ± 6.49 17.65 ± 21.03 0.035 Hospital LOS 20.63 ± 9.08 35.13 ± 24.21 0.003 Total ventilator days 6.77 ± 7.31 18.55 ± 24.94 0.016 Post-VATS ventilator days 5.00 ± 7.39 11.33 ± 18.77 0.079 Chest tube use days 11.70 ± 5.37 16.38 ± 10.77 0.037 Post-VATS chest tube use days 9.00 ± 4.59 9.51 ± 10.36 0.802 Positive microbial cultures Sputum 10 (33.3%) 16 (51.6%) 0.198 Pleural effusion 2 (6.7%) 9 (29.0%) 0.043 reports suggest that early evacuation of the pleural col- The basic demographic data were the same in each lection within 4–5 days after trauma could achieve better group in this study. The greatest difference between these clinical outcomes [10, 15, 16]. In this study, early surgical two groups was found in limb injuries. All patients in intervention in chest injury really could obtain a better Group 1 had limb injuries, such as open fractures or neu- outcome in patients with stable head injury. rovascular injuries, requiring early damage control inter- Acute respiratory failure is prone to induce post-trau- vention. During these surgeries, VATS was performed matic infections [8, 14]. These two complications are the simultaneously for retained pleural collections. In most main reasons for prolonging the in-hospital course. These cases, the surgical time of VATS was less than 30 min, complications occur with high frequency in the case of without any increase in the total surgical periods. combined head and chest injuries. In this study, half of the In this study, time periods of ventilator and chest tube patients (36/61, 59.0%) required emergent endotracheal use after VATS were collected to evaluate the successful tube intubation because of a change of consciousness or a rates of VATS between the two groups. The total time rapid decrease in oxygen saturation. The rate of acute periods of ventilator and chest tube usage were both longer respiratory failure was equal in the two groups. Many in Group 2, but the postoperative time periods were the studies have proofed that shorting the periods of ventilator same in the two groups, signifying that VATS was per- dependent could also decrease the rate of pneumonia. In formed with same efficacy in both groups. The longer total this study, there were 26 patients who had post-traumatic time periods in Group 2 resulted from the longer waiting pneumonia that were derived from aspiration pneumonia time for monitoring the neurological condition. In this and nosocomial pneumonia. The rate of enterobacterial study, the VATS could be performed safely within 4 days cultures from sputum was similar in each group. It means or less. All patients’ GCS scores were improved when they that rate of aspiratory pneumonia was also equal in each were discharged, and the GCS at discharge showed no group. In Group 1, early VATS could re-expand the lung difference between the two groups, signifying that the early parenchyma earlier that could restore the lung function surgical procedure did not influence these patients’ brain more rapidly. By decreasing the ventilator dependent condition. The routine waiting time of at least 4 days in periods, the rate of nosocomial pneumonia may also be head injury patients without indication of emergency decreased indirectly. craniotomy may be unnecessary. The rate of positive microbial cultures from pleural Due to advancement of ICU care, the mortality of severe effusion obtained during VATS was much lower in Group and multiple trauma patients is much lower than before 1 with statistical difference. It means that early VATS in [2, 16, 17]. In this study, only three patients expired: the Group 1 could remove retained hemothorax more early to mortality rate was 4.9% (3/61). One patient in Group 1 had prevent further pleural infections. That is, the retained progressively scattered intracranial hemorrhage and hemothorax had been infected with bacteria in most Group unfortunately expired due to central failure. The other two 2 patients. The antibiotics treatment course in these in Group 2 had severe pneumonia-induced septic shock patients will be lengthened. Due to the early control of that induced multiple-organ failure. The other patients all infection in Group 1, the antibiotic requirements and cost recovered after comprehensive care in the ICU. Therefore, were both decreased. This also made it easier to gradually under detail monitoring and treatments, VATS could be discontinue the ventilator use. These advantageous effects performed earlier in patients whose brain condition is rel- played an important role in shortening the whole hospital atively stable. course. 123 2066 World J Surg (2018) 42:2061–2066 This is the first study to observe the early VATS inter- References vention in chest trauma with brain injury. However, this 1. Brain Trauma Foundation, American Association of Neurological study has several limitations. First, the case numbers in this Surgeons, Congress of Neurological Surgeons (2007) Guidelines study were low. Only 61 patients who qualified for the for the management of severe traumatic brain injury. J Neuro- inclusion criteria during the study period were enrolled. It trauma 24(Suppl 1):S1–106 was difficult to find qualifying patients because only 10% 2. Robertson CS, Valadka AB, Hannay HJ et al (1999) Prevention of secondary ischemic insults after severe head injury. Crit Care of chest blunt trauma cases exhibit retained pleural col- Med 27(2086–209):5 lections, and also because cases of severe head injuries 3. Kalb DC, Ney AL, Rodriguez JL et al (1998) Assessment of the with emergent craniotomy were excluded. However, the relationship between timing of fixation of the fracture and sec- preoperative status and demographic matching of the two ondary brain injury in patients with multiple trauma. Surgery 124:739–744 (discussion 744–735) groups decrease the bias, and the power of this study is 4. Yokobori S, Watanabe A, Matsumoto G et al (2011) Time course 0.84; therefore, fewer case numbers may not influence the of recovery from cerebral vulnerability after severe traumatic accuracy of the statistical analysis. Second, although this brain injury: a microdialysis study. J Trauma 71:1235–1240 study was based on prospective data collection, some of the 5. Heniford BT, Carrillo EH, Spain DA et al (1997) The role of thoracoscopy in the management of retained thoracic collections parameters were collected from chart reviews. Errors may after trauma. Ann Thorac Surg 63(940–94):3 have occurred during recording. To prevent this bias, a 6. Helling TS, Gyles NR 3rd, Eisenstein CL et al (1989) Compli- senior trauma surgeon supervised a rechecking of the exact cations following blunt and penetrating injuries in 216 victims of data. Third, many factors could influence the duration of chest trauma requiring tube thoracostomy. J Trauma 29:1367–1370 acute respiratory failure. Severe abdominal injury could 7. Eddy AC, Luna GK, Copass M (1989) Empyema thoracis in lengthen the in-hospital stay. Chronic medical problems patients undergoing emergent closed tube thoracostomy for tho- such as chronic obstructive pulmonary disease, liver cir- racic trauma. Am J Surg 157(494–49):7 rhosis and chronic heart failure could also increase mor- 8. Richardson JD, Carrillo E (1997) Thoracic infection after trauma. Chest Surg Clin N Am 7(401–42):7 bidity and mortality. All of these biases were excluded 9. Meyer DM, Jessen ME, Wait MA et al (1997) Early evacuation of from enrollment in this study. In addition, aspiration traumatic retained hemothoraces using thoracoscopy: a prospec- pneumonia is another complication after trauma, especially tive, randomized trial. Ann Thorac Surg 64:1396–1400 (discus- for head injury with unconscious status [18]. If the rate of sion 1400–1391) 10. Carrillo EH, Richardson JD (2005) Thoracoscopy for the acutely positive culture from enterobacteria was the same in these injured patient. Am J Surg 190(234–23):8 two groups, this bias would therefore also be decreased. 11. McManus K, McGuigan J (1994) Minimally invasive therapy in Finally in recent studies, thrombolytic agents provide thoracic injury. Injury 25(609–61):4 another choice for treating retained hemothorax [19]. 12. Dennis BM, Gondek SP, Guyer RA et al (2017) Use of an evi- dence-based algorithm for patients with traumatic hemothorax Patients who are not candidates for VATS, intra-pleural reduces need for additional interventions. J Trauma Acute Care irrigation with thrombolytic agents may also be considered. Surg 82(728–73):2 13. Mergo PJ, Helmberger T, Didovic J et al (1999) New formula for quantification of pleural effusions from computed tomography. J Thorac Imaging 14(122–12):5 Conclusion 14. Chou YP, Lin HL, Wu TC (2015) Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin In patients with a combination of chest and head injuries Pulm Med 21(393–39):8 without indication of emergency craniotomy, earlier VATS 15. Morales Uribe CH, Villegas Lanau MI, Petro Sanchez RD (2008) Best timing for thoracoscopic evacuation of retained post-trau- could be performed safely to obtain better clinical matic hemothorax. Surg Endosc 22(91–9):5 outcomes. 16. Smith JW, Franklin GA, Harbrecht BG et al (2011) Early VATS for blunt chest trauma: a management technique underutilized by Compliance with ethical standards acute care surgeons. J Trauma 71:102–105 (discussion 105–107) 17. Tuttle MS, Smith WR, Williams AE et al (2009) Safety and Conflict of interest All the authors have no conflict of interest of any efficacy of damage control external fixation versus early defini- financial and personal relationships with other people, or organiza- tive stabilization for femoral shaft fractures in the multiple-in- tions in relation to this study. jured patient. J Trauma 67(602–60):5 18. Lin HL, Huang WY, Yang C et al (2014) How early should Open Access This article is distributed under the terms of the VATS be performed for retained haemothorax in blunt chest Creative Commons Attribution 4.0 International License (http://crea trauma? Injury 45:1359–1364 tivecommons.org/licenses/by/4.0/), which permits unrestricted use, 19. Kumar S, Rathi V, Rattan A et al (2015) VATS versus distribution, and reproduction in any medium, provided you give intrapleural streptokinase: a prospective, randomized, controlled appropriate credit to the original author(s) and the source, provide a clinical trial for optimum treatment of post-traumatic Residual link to the Creative Commons license, and indicate if changes were Hemothorax. Injury 46:1749–1752 made.

Journal

World Journal of SurgerySpringer Journals

Published: Jan 5, 2018

References

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off