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Trauma represents the leading cause of death in patients younger than 45 years old. The introduction of multidisciplinary trauma teams has resulted in an improvement in patients` outcome. The thoracic surgeon plays an invaluable role as a member of the multidisciplinary team that includes an emergency physician, surgical figure, an anaesthetist, a radiology technician plus a number of nurses. Thorough knowledge of the physiological mechanism of injury and an intensive training have contributed massively in improving the outcomes. Different surgical approaches have to be considered in order to provide the best outcome to the acute patient with chest injury.
© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 |
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Despite substantial advances in trauma care over the last
few decades, trauma still represents the leading cause of
death in patients younger than 45 years old (1-3). Failure
in providing sufcient specialized care in the early phase of
major trauma led to the development of a modern model
of civilian trauma system with the Emergency Medical
System Act Public Law 93-155 issued by the United States
Congress in 1973 (4). One of the major results from this
law was the introduction of multidisciplinary trauma teams
with the purpose to stabilize the patient and reduce the time
span between the diagnosis and the treatment, with the
only goal to improve overall survival. Several studies (5-8)
have concluded that the inclusion of different specialties is
essential to reduce mortality.
As effectively described by Ludwig et al. (9) management
of chest trauma is based on three distinct levels of care
ranging from prehospital trauma support, hospital trauma
life support and surgical trauma life support. During
the primary assessment of the trauma patient as per the
Advanced Trauma Life Support (ATLS) (protocol, life-
threatening injuries should be excluded or managed. These
include airway obstruction, pneumothorax, haemothorax,
ail chest and cardiac tamponade. Subsequently, potentially
life-threatening injuries should be dealt with or ruled
out, including pulmonary and myocardial contusion,
diaphragmatic injury and disruption of the tracheobronchial
tree, oesophagus and aorta.
The thoracic surgeon plays an invaluable role as a
member of an extended, multidisciplinary team, whose
main goal is to reduce morbidity and mortality secondary
to trauma. A good knowledge and profound understanding
of the underlying pathophysiologic mechanisms associated
with thoracic trauma is necessary to guide the management
of this challenging clinical entity.
The role of a multidisciplinary team in chest wall trauma management
Davide Patrini1, David Lawrence1, Savvas Lampridis1, Fabrizio Minervini2, Lorenzo Giorgi3,
Roberto Palermo3, Martin Hayward1, Marco Scarci4, Joachim Schmidt5, Benedetta Bedetti5
1Department of Thoracic Surgery, University College London Hospitals, London, UK; 2Department of Thoracic Surgery, Cantonal Hospital
Lucerne, Lucerne, Switzerland; 3Department of Thoracic Surgery, University of L’Aquila, L’Aquila, Italy; 4Department of Thoracic Surgery, San
Gerardo Hospital, Monza, Italy; 5Department of Thoracic Surgery, Malteser Hospital, Bonn, Germany
Contributions: (I) Conception and design: D Patrini, B Bedetti; (II) Administrative support: M Scarci; (III) Provision of study materials or patients:
M Hayward, J Schmidt; (IV) Collection and assembly of data: L Giorgi, R Palermo; (V) Data analysis and interpretation: D Patrini, B Bedetti, S
Lampridis; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Mr. Davide Patrini. Consultant Thoracic Surgeon, Thoracic Surgery Department, University College London Hospitals, 16-18
Westmoreland St. W1G 8PH, London, UK. Email:
Abstract: Trauma represents the leading cause of death in patients younger than 45 years old. The
introduction of multidisciplinary trauma teams has resulted in an improvement in patients` outcome.
The thoracic surgeon plays an invaluable role as a member of the multidisciplinary team that includes
an emergency physician, surgical figure, an anaesthetist, a radiology technician plus a number of nurses.
Thorough knowledge of the physiological mechanism of injury and an intensive training have contributed
massively in improving the outcomes. Different surgical approaches have to be considered in order to
provide the best outcome to the acute patient with chest injury.
Keywords: Thoracic surgery; chest wall trauma; multidisciplinary team
Received: 11 November 2019. Accepted: 29 November 2019.
doi: 10.21037/jovs.2019.12.01
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Journal of Visualized Surgery, 2019
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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 |
The concept and composition of the trauma
A team spirit is mandatory for appropriate delegation of
tasks among members involved in the assessment and
management of the trauma patient. In this context, a
horizontal distribution of tasks has been proven to be
effective in improving clinical outcomes (10). Regarding the
composition of the trauma team, variations exist between
different countries and healthcare system (11,12); however,
several factors are often common. In a basic set up, the
trauma team is often led by a surgeon who coordinates
according to the ATLS guidelines; his role can also be
taken by an emergency physician. The rest of the team is
composed by an anaesthetist, a radiology technician and
a variable number of nurses. Airway management, which
takes priority over all the other tasks, is usually carried
out by the anaesthetist. His tasks also include intubation,
ventilation and airway-associated interventions. The
surgeon is responsible for the coordination of the trauma
team, the primary survey of the patient and potential
operative procedures. The radiology technician performs
imaging investigations and may assist the surgeon in
their interpretation. A radiologist will be required if a
formal report is needed and in case the patient undergoes
computed tomography (CT). Finally, the nursing staff make
the alert calls, record vital information, take blood samples,
place monitoring devices, set up the ventilator and assists
the anaesthetist and the surgeon. It is worth noting that
in some hospitals a neurologist or a neurosurgeon is often
involved to assess more accurately the Glasgow Coma Scale
score, focal neurological decit and pupillary light response.
Prehospital management
Patient assessment with clinical examination including,
inspection, palpation, percussion and auscultation are
essential to recognize major thoracic injuries, such as open
and tension pneumothorax, hemothorax, flail chest and
lung contusion. Tension pneumothorax is the most frequent
reversible cause of cardiac arrest (12). Therefore, rapid
and accurate assessment for diminished chest expansion
and absence of breath sounds on the ipsilateral side can
be lifesaving. Needle decompression is the first line of
treatment followed by insertion of a chest drain.
Diagnostic imaging
Patients with thoracic trauma are at high risk for both
intrathoracic and intraabdominal injuries, depending on the
mechanism and energy of the injury. Thorough assessment
with various imaging modalities is advised in all but few
cases, in which clinical suspicion is high and any delay
in treatment may prove catastrophic. Imaging typically
includes extended focused assessment with sonography
in trauma (eFAST) for rapid detection of hemothorax,
hemopericardium, pneumothorax and intraperitoneal
bleeding (13,14). More advanced imaging investigations
include CT of the chest, which provides more detailed
information. A CT is characterised by greater sensitivity
and specificity compared to a plain chest radiograph,
although the latter is generally sufcient to detect clinically
significant injuries. However, a CT should be avoided in
hemodynamically unstable patients. In these cases, the
importance of eFAST to rule out life threatening injuries
cannot be underestimated.
Emergency room management
A full assessment of the patient should be performed by
the trauma team in the emergency room according to a
predefined algorithm. Thorough and repeated clinical
examination, review of the mechanism of thoracic injury
and information about the past medical history of the
patient are considered invaluable tools for successful
management. According to the ATLS guidelines (15), a
thoracic surgeon should be involved in case of persistent
blood loss after chest drain insertion (1,500 mL acutely or
more than 200 mL per hour for 3–4 consecutive hours),
severe subcutaneous emphysema, massive haemoptysis,
penetrating chest trauma and substantial air leak from
a chest tube. Immediate surgery is advised in case of
persistent intrathoracic bleeding, endobronchial blood loss
with ventilation impairment, penetrating injury and flail
Surgical management
In order to access the chest in an emergency setting,
anterolateral thoracotomy is the access of choice permitting
good exposure of thoracic organs. Differently from the
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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 |
classic posterolateral thoracotomy a more anterior approach
will avoid the rotation of the patient on a side. In 20% pf
patients the thoracotomy may be insufficient to visualize
all the lesions therefore alternative approach such as
Clamshell (transverse sternotomy and bilateral anterolateral
thoracotomy) may be required (16).
In the management of chest trauma there is also a role
for minimally invasive surgery: indications for video assisted
thoracoscopic surgery (VATS) may include (I) penetrating
injury with minimal blood loss on a stable patient; (II)
hemothorax; (III) empyema; (IV) persistent air leak; (V)
concerns about diaphragmatic involvement.
VATS has shown its value in the management of
pleural space involvement in the non-critical stable
patient (17). Thoracoscopic assessment of the pleural cavity
can demonstrate misdiagnosed injuries and lesion and
treat a potential persisting hemothorax (18). Jin et al. (19)
highlighted an advantage of VATS over open thoracotomy
approach in a randomized trial demonstrating a lower rate
of ARDS rates comparing to open thoracotomy patients.
The benefits of VATS are evident as long as strict
inclusion criteria are respected: in a hemodynamically
unstable patient with severe chest or cardiac vessel injury
an open approach must be the preferred choice leaving
no place for thoracoscopic surgery that can only have a
negative impact on outcomes by delaying the unavoidable
conversion to open thoracotomy (20).
The effect of the trauma team on clinical
The aim of the trauma team is to reduce morbidity and
mortality and thus improve patient outcome. Indeed, since
the introduction of the trauma team worldwide, there
is strong evidence to support that patient outcome has
improved significantly (21). This improvement is noted
not only in the improved management of moderately
and severely injured patients, but also in the higher rate
of unexpected survivors due to the efficient role of the
trauma team. Contrariwise, patients who meet the criteria
for trauma call and are not treated by a trauma team,
demonstrate higher rates of morbidity and mortality (22).
Trauma team training
Advance trauma life support course (ATLS)
The first ATLS course was held in USA in 1978. It
was originally developed for doctors in rural areas and
subsequently expanded by the American College of
Surgeons in 1980. The ATLS course is now widely accepted
and has resulted in better patient outcomes in several
studies (23).
Simulation-based training creates a situation where
certain skills are applied as in a real-world environment.
Skill development is achieved through repetition and
constructive feedback (24). There are several modalities of
simulation-based training, which all share the same goal: to
enable the trainee to acquire a wide set of skills. There is no
consensus whether using a standardized manikin or a patient
will make a difference when considering communication,
cooperation and leadership skills (25). A study by Wisborg
and colleagues (26) confirmed this observation, although
considering that the outcome is measured in participant’s
assessment of their role and the degree of realism rather
than with a more objective outcome score.
Several studies have been published on the benefits of
recording simulated or actual trauma situations (27-29). The
benets of this are threefold: rstly, recorded video can be
used for educational purposes, by creating opportunities to
review and modify behaviour in a controlled environment;
secondly, it can be used to assess and measure the adherence
to the ATLS protocol; lastly, recorded video can be used
also for research purposes (30).
Leadership and communication skills are considered of
paramount importance in the effective management of
a trauma team. Moreover, appropriate supervision and
support by the senior members, as well as self-awareness
and ability to seek help by the junior members, are
warranted to improve the efcacy of the team. Furthermore,
thorough knowledge of the role of each member and clearly
dened tasks may have a signicant impact on the clinical
outcome of trauma patients. Management of these patients
should follow general principles of well-established trauma
protocols and, depending on the pathophysiology of each
individual case, it can range from simple observation to
salvage surgery (Figure 1).
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Conicts of Interest: The authors have no conicts of interest
to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
1. Centers for Disease Control and Prevention. Available
2. Central Bureau of Statistics of Netherlands. Available
3. Norton R, Kobusingye. Injuries. N Engl J Med
4. Harvey JC. The Emergency Medical Service Systems Act
of 1973. JAMA 1974;230:1139-40.
5. West JG, Trunkey DD, Lim RC. Systems of trauma care.
A study of two counties. Arch Surg 1979;114;455-60.
6. West JG, Coles RH, Gazzaniga AB. Impact of
regionalization. The Orance County Experience. Arch
Surg 1983;118:740-4.
7. Clemmer TP, Orme JF. Outcome of critically injured
patients treated at level 1 trauma centers versus full-service
community hospitals. Crit Care Med 1985;13:861-3.
8. Shatney CH. Initial Resuscitation and assessment of
patients with multisystem blunt trauma. South Med J
9. Ludwig C, Koryllos A, Management of Chest Trauma.
Journal of Thoracic Disease 2017;9:S172-7.
10. Liberman M, Mulder DS, Jurkovich GJ. The Association
between trauma system and trauma center components
and outcomes in a mature regionalized trauma system.
Surgery. 2005:137:647-58.
11. Driscoll PA, Vincent CA. Organizing an efcient trauma
team. Injury 1992;23:107-10.
12. Mistry N, Bleetman A, Roberts KJ. Chest decompression
during the resuscitation of patients in prehospital traumatic
cardiac arrest. Emerg Med J 2009;26:738-40.
13. Röthlin MA, Nöf R, Amgwerd M. Ultrasound in blunt
abdominal and thoracic trauma. J Trauma 1993;34;488-95.
14. Kirkpatrick AW, Sirois M, Laupland KB, et al.
Handheld thoracic sonography for detecting post
traumatic pneumothoraces, the extended focused
assessment with sonography for trauma (eFAST). J
Trauma 2004;57:288-95.
15. ATLS Subcommittee., American College of Surgeons’
Committee on Trauma., International ATLS working
group. Advanced trauma life support (ATLS®): the ninth
edition. J Trauma Acute Care Surg 2013;74:1363-6.
16. Karmy-Jones R, Nathens A, Jurkovich G, et al. Urgent
and emergent thoracotomy for penetrating chest trauma. J
Trauma 2004;56;664-8.
17. Schots JP, Vissers YI, Hulsewe KW, et al. Addition of
Video-Assisted Thoracoscopic Surgery to the Treatment
of Flail Chest. Ann Thorac Surg 2017;103:940-4.
18. Chou YP, Lin HL, Wu TC. Video-Assisted thoracoscopic
surgery for retained hemothorax in blunt chest trauma.
Curr opin Pulm Med 2015;21:393-8.
19. Jin J, Song B, Lei YC, et al. Video-Assisted thoracoscopic
surgery for penetrating chest trauma. Chin J Traumatol
20. Mizobuchi T, Iwai N, Kohno H, et al. Delayed Diagnosis
of traumatic diaphragmatic rupture. Gen Thorac
Cardiovasc Surg 2009;57:430-2.
21. Petrie D, Lane P, Stewart TC. An Evaluation of patient
outcome comparing trauma team activated versus trauma
team not activated using TRISS analysis. Trauma and
Injury Severity Score. J Trauma 1996;41:870-3.
22. Rainer TH, Cheung NK, Yeung JH, Graham CA. Do
Trauma Teams make a difference? A single centre registry
study. Resuscitation 2007;73:374-81.
23. Carmont MR. The Advanced Trauma Life Support
course: a history of its development and review of related
literature. Postgrad Med J 2005:81:87-91.
Video 1. Learning points in chest wall
trauma management
Davide Patrini*, David Lawrence, Savvas
Lampridis, et al.
Department of Thoracic Surgery, University
College London Hospitals, London, UK
Figure 1 Learning points in chest wall trauma management (31).
Available online:
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24. Shapiro MJ, Morey JC, Small SD, et al. Simulation based
teamwork training for emergency department staff: doesit
improve clinical team performance when added to an
existing didactic teamwork curriculum? Qual Saf Health
Care 2004;13:417-21.
25. Capella J, Smith S, Philip A, et al. Teamwork Training
Improves the clinical care of trauma patients. J Surg Educ
26. Wisborg T, Braettebo G, Brinchmann Hansen A, Hansen
KS. Mannequin or standardized patient: participants’
assessment of two training modalities in trauma team
simulation. Scand J Trauma Resusc Emerg Med
27. Santora TA, Trooskin SZ, Blank CA, et al. Video
assessment of trauma response: adherence to ATLS
protocols. Am J Emerg Med 1996;14:564-9.
28. Hoyt DB, Shackford SR, Fridland P, et al. Video recording
trauma resuscitations: on effective teaching technique. J
Trauma 1988;28:435-40.
29. Blank-Reid CA, Kaplan LJ. Video recording trauma
resuscitation: a guide to system set up, personnel concerns
and legal issue. J Trauma Nurs 1996;3:9-12.
30. Scherer LA, Chang M, Meredith JW, Battistella FD.
Video tape review leads to rapid and sustained learning.
Am J Surg 2003;185:516-20.
31. Patrini D, Lawrence D, Lampridis S, et al. Learning points
in chest wall trauma management. Asvide 2019;6. Available
doi: 10.21037/jovs.2019.12.01
Cite this article as: Patrini D, Lawrence D, Lampridis S,
Minervini F, Giorgi L, Palermo R, Hayward M, Scarci M,
Schmidt J, Bedetti B. The role of a multidisciplinary team in
chest wall trauma management. J Vis Surg 2019.
... A trauma team consisting of multidisciplinary experts, such as a surgeon, anesthesiologist, radiologist, and nursing team, is required to manage such complex and uncommon cases. 10 An emergency thoracotomy should be done if there are massive bleeding, bronchial injury, esophageal injury, pericardial tamponade, diaphragmatic injury, great vessel injuries, and acute deterioration of the patient's condition. 11 Preoperative preparations are intended to prevent further migration of the foreign body by doing proper positioning and giving sufficient analgesics. ...
Full-text available
A foreign body in the bronchus due to a ballistic projectile is very uncommon. A 45-year-old man presented to the hospital after being accidentally shot. The initial radiographic assessment found a bullet in his left thoracic cavity. With the help of an X-ray, an urgent left posterolateral thoracotomy was conducted, but no foreign body was found. The foreign body had migrated to the contralateral chest cavity, as determined by the C-arm. On the following day, a thorax computed tomography scan was conducted, and it was discovered that the foreign body had already migrated to the right lower bronchus. A right thoracotomy was then performed to remove the foreign body. He was moved to the intensive care unit and discharged with a stable condition. In conclusion, migration of a foreign body in the bronchus is rare. A thorough strategy is required to prevent the object from migrating even further.
Full-text available
In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
Full-text available
For penetrating thoracic trauma, there is no consensus on whether operative exploration or conservative treatment is better. In this study, we compared the clinical effect of video-assisted thoracoscopic surgery (VATS) and thoracotomy on the patients with penetrating thoracic trauma. From January 2000 to December 2010, 123 patients with penetrating thoracic trauma were treated in Affiliated Hospital of Chengdu University. Based on the inclusion criteria, 80 patients were enrolled and randomly assigned into VATS and thoracotomy group. The operation time, amount of bleeding and drainage in VATS group were all lower than traditional operation (p < 0.05). The results indicate that VATS has the merits of shorter operation time, non-blind area, exact surgical path and less bleeding comparing with traditional operation.
Full-text available
Trauma team training using simulation has become an educational compensation for a low number of severe trauma patients in 49 of Norway's 50 trauma hospitals for the last 12 years. The hospitals' own simple mannequins have been employed, to enable training without being dependent on expensive and advanced simulators. We wanted to assess the participants' assessment of using a standardized patient instead of a mannequin. Trauma teams in five hospitals were randomly exposed to a mannequin or a standardized patient in two consecutive simulations for each team. In each hospital two teams were trained, with opposite order of simulation modality. Anonymous, written questionnaires were answered by the participants immediately after each simulation. The teams were interviewed as a focus group after the last simulation, reflecting on the difference between the two simulation modalities. Outcome measures were the participants' assessment of their own perceived educational outcome and comparison of the models, in addition to analysis of the interviews. Participants' assessed their educational outcome to be high, and unrelated to the order of appearance of patient model. There were no differences in assessment of realism and feeling of embarrassment. Focus groups revealed that the participants felt that the choice between educational modalities should be determined by the simulated case, with high interaction between team and patient being enhanced by a standardized patient. Participants' assessment of the outcome of team training seems independent of the simulation modality when the educational goal is training communication, co-operation and leadership within the team.
Full-text available
Tension and bilateral pneumothorax can cause or contribute to death following trauma. A surgical incision (thoracostomy) or needle decompression through the chest wall rapidly treats these conditions. Resuscitation of patients in traumatic cardiac arrest focuses on treating common and reversible life-threatening conditions. A study was undertaken to observe the practice, findings and outcome of chest decompression when performed as part of the resuscitation strategy of these patients by air ambulance crews. Patients in prehospital traumatic cardiac arrest were identified over a 39-month period from an air ambulance database. The use of thoracostomy or needle decompression was identified together with indications, findings and outcome. Primary outcome was return of cardiac output by arrival at hospital. 18 of 37 cases underwent chest decompression (17 thoracostomy, 1 needle decompression). Four patients had a return of cardiac output (3 tension pneumothorax, 1 bilateral pneumothorax). Six further cases were positive for intrathoracic injury. In 2 cases the injuries identified were incompatible with life and resuscitation efforts were consequently ceased. Chest decompression in traumatic cardiac arrest identifies and treats a high proportion of potentially life-ending injuries and should be considered as part of the resuscitation effort of patients in traumatic cardiac arrest. In a proportion of patients, non-survivable injuries are identified which guide resuscitation efforts.
Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.
Background: Video-assisted thoracoscopic surgery (VATS) is increasingly used in chest trauma for diagnostic and therapeutic purposes. In this report we describe our single-institutional experience with VATS in the surgical treatment of patients with flail chest after high-energy trauma. Methods: From January 2013 to July 2014, 15 patients with flail chest after high-energy trauma were treated in our hospital. The Injury Severity Score (ISS) ranged from 16 to 44. Rib fixation was performed with precontoured plates or intramedullary splints. In all, patients we additionally used VATS to explore the thoracic cavity and evacuate any hemothorax. Results: In 10 patients a prominent hemothorax was present, which needed evacuation. The median operative time was 120 minutes (range, 60 to 180 minutes), with a median blood loss of 150 mL (range, <100 to 400 mL). The mean stay in the intensive care unit was 5.27 days (SD 6.79). Ten patients were extubated directly after operation in the operating room. The other 5 patients were extubated after 1 to 13 days. The mean duration of mechanical ventilation was 2 days (SD 4.17). No patient required a tracheostomy. Three patients had minor postoperative adverse events. All patients were discharged after 6 to 44 days (mean, 11.9 hospitalization days) (SD 9.57). Conclusions: We believe VATS is effective and safe and can be of additional value by providing the possibility to adjust the planned incision for rib fixation and decrease the area of muscle destruction. Additional pulmonary or mediastinal pathologic conditions can be identified and complete evacuation of hemothorax can be achieved simultaneously.
We report a case of late presentation of traumatic rupture of the diaphragm discovered incidentally on chest radiography (CXR) during an annual medical checkup. A 60-year-old man suffered severe blunt trauma from heavy steel frames collapsing against his back, resulting in pelvic and femoral fractures as well as pulmonary contusions. The patient recovered, but 10 months later CXR performed for lung cancer surveillance during an annual medical checkup revealed a traumatic rupture of the diaphragm. Video-assisted thoracic surgery was performed with reduction of the intestine and primary closure of the diaphragmatic defect. The patient recovered uneventfully. This report serves as a useful reminder that a medical history of severe blunt trauma should provoke a high index of suspicion for diaphragmatic rupture during annual medical surveillance.
Cases of motor vehicle trauma victims who died after arrival at a hospital were evaluated in both Orange County (90 cases) and in San Francisco County (92 cases), Calif. All victims in San Francisco County were brought to a single trauma center, while in Orange County they were transported to the closest receiving hospital. Approximately two thirds of the non-CNS-related deaths and one third of the CNS-related deaths in Orange County were judged by the authors as potentially preventable; only one death in San Francisco County was so judged. Trauma victims in Orange County were younger on the average, and the magnitude of their injuries was less than for victims in the San Francisco County. We suggest that survival rates for major trauma can be improved by an organized system of trauma care that includes the resources of a trauma center.
A prospective analysis of 207 trauma patients, from three internationally recognized trauma centres, showed that trauma teams in which staff carry out allocated tasks simultaneously have the quickest resuscitation times. This finding was further tested by introducing these changes into a fourth centre. A comparison of resuscitation stage times was made in 26 patients before and 24 patients after the introduction of the organizational changes. Significant time reductions were found in all the stages, except the time taken to examine the patient. The time taken to complete the resuscitation was reduced by over half from 122 to 56 min. Significant time reductions applied even when variations in the type of patient, the team size or seniority of the team leader was taken into account. Recommendations for the organization of trauma teams are made.