Setting and patients
This observational study was conducted in a level I trauma medical center in Southern Taiwan with 1300 beds serving about 1200 trauma visits per month. During the study period, all patients admitted from our emergency department (ED) with major trauma with both blunt head and thoracic injuries were included. All patients’ data included demographics, the mechanism of injury, the number of ribs fractured, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) at the emergency department and discharge, concomitant chest injuries, pulmonary contusion scores, postoperative complications, acute respiratory failure, number of ventilator days, length of stay (LOS) in the intensive care unit (ICU), and hospital LOS were prospectively collected with a standard form. A senior trauma surgeon reviewed all the data for accuracy. The ethics committee of the study hospital approved the study.
Patients older than 14 years of age admitted to the trauma unit in this hospital with blunt head and chest trauma were included. All trauma patients received computed tomography (CT) of the brain and chest, and those who had hemothorax or pneumothorax were treated with a 32F straight thoracostomy tube during initial evaluation at the ED with low-negative pressure (-15cmH
2O). After detailed evaluations, all of these patients were admitted into the intensive care unit (ICU). Chest roentgenograms were routinely followed up daily. The chest tubes were adjusted when infiltration of routine chest x-ray is found. Bronchoscopy for sputum suction was also applied when atelectasis of lung was suspected. All of these patients received a brain CT and chest CT again at 24 to 48 h after trauma to evaluate the condition of intracranial hemorrhage and the volume of pleural collection [
12]. Patients whose secondary chest CT showed a retained pleural collection persisting at more than 300 ml were considered for VATS. The retained hemothorax is calculated by formula
V (in mL) =
d2 ×
X ×
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 and limbs with an Abbreviated Injury Score (AIS) over three were excluded. Patients with severe head injury with a mass effect for which an emergent craniotomy should be performed immediately were also excluded. Patients who were hemodynamically unstable, had more than 1500 mL of blood on placement of the initial tube thoracostomy, or had ongoing blood loss of more than 250 mL/h and had received an emergency thoracotomy were not included. Patients with blunt aortic injury were also excluded, as were patients with severe medical disease including chronic heart failure, end-stage renal disease, severe liver cirrhosis, and chronic obstructive pulmonary disease.
Time periods from trauma to VATS performance were variable in these patients. According to study of Yokobori et al. [
4], these procedures are usually delayed, being performed more than 4 days after trauma for brain autoregulation recovery. In this study, some patients received VATS within 4 days after injury. For example, if a patient had a limb fracture needing fixation or a huge crush wound requiring debridement within short time after trauma, VATS would be arranged with these associate surgeries at the same time. Therefore, patients were divided into two groups based on the day of VATS performance: Group 1, within 4 days; Group 2, 5 or more days.
In this study, all the patients with head injury were observed without surgical intervention and received VATS due to retained hemothorax. The VATS was performed in the operating room under general anesthesia. Routine one dose of prophylactic antibiotics was given at the beginning of VATS. Evacuations of retained pleural collections were performed via VATS procedures. The pleural effusions were sent for microbial cultures during VATS in both groups. Finally, each patient was transferred to trauma ICU for further postoperative care. After either procedure, the thoracostomy tubes were connected to suction with low-negative pressure (-15cmH
2O) and were removed at the discretion of the thoracic surgeons when drainage was less than 100 mL/24 h and no air leaks were present [
14].
Post-trauma infection included positive microbial cultures of sputum, pleural effusion, and blood. Postoperative outcomes were in-hospital mortality, length of ventilator use, coma scale, and ICU and hospital LOS.