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30% of patients with blunt thoracic aortic injury (BTAI) can have concomitant traumatic brain injury (TBI), with mortality nearing 20%. Conflicting blood pressure goals may influence decision and timing of thoracic endovascular aortic repair (TEVAR). This study analyzed management and outcomes in patients with concomitant TBI/BTAI. Patients with concomitant TBI/BTAI and BTAI were identified in our trauma registry. Descriptive statistics and logistic regression compared management and outcomes. Twenty patients had concomitant TBI/BTAI. 46 patients had BTAI alone. 9(13%) patients with concomitant TBI/BTAI and 30(45%) patients with BTAI alone underwent TEVAR. There was no difference in overall mortality (OR 0.29, 0.05–1.55 CI, p ​= ​0.12), aortic-related mortality (x2 3.51, p ​= ​0.06), incidence of TEVAR (x2 1.59, p ​= ​0.10) or timing to TEVAR (t ​= ​−1.6056, p ​= ​0.06) between patients with concomitant TBI/BTAI and BTAI alone. There was no difference in outcomes or interventions in patients with TBI/BTA vs BTAI alone in this small, hypothesis-generating single institutional trial. [Display omitted] •Concomitant TBI/BTAI has a mortality around 20%.•Conflicting optimal blood pressure exists - higher for TBI, lower for BTAI.•BTAI repair should be considered in patients with concomitant TBI.•A larger multi-institutional trial is needed.

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

IntroductionBlue light (peak wavelength 442 nm) has been shown to modulate the immune response in preclinical models of intra-abdominal sepsis and pneumonia. In vivo pathways involve optic nerve stimulation with transmission to the central nervous system, activation of parasympathetic pathways terminating at the spleen, and downstream immune effects including decreased inflammatory tissue damage and improved pathogen clearance. Related effects on pain mediators including proinflammatory cytokines (interleukin 6, TNF- α) and autonomic tone (increased parasympathetic outflow) suggest possible analgesic properties that would be highly relevant to a trauma population.Methods and analysisThis is a randomised controlled trial in which adult trauma inpatients (≥18 years) with painful rib fractures will be allocated 1:1:1 to three arms: bright blue light intervention (peak 442 nm, ~1400 lux), bright full-spectrum light comparison (~1400 lux) and usual ambient light control. Bright light exposures will be administered for 4 consecutive hours daily for up to 3 days. The primary outcome will be any measurable changes in chest wall pain intensity during deep breathing, quantified using an 11-point Numerical Rating Scale. Secondary outcomes will assess chest wall pain intensity at rest, opioid requirements, delirium incidence, pulmonary complication incidence, hospital-free and intensive care unit-free days, and physiological markers of autonomic nervous system, circadian, and immune activation. Sample size analysis yields a total of 75 participants needed to detect a 2-point difference in pain scores with >80% power and assuming a 20% non-completion rate.Ethics and disseminationFull ethical approval for this trial has been granted by the University of Pittsburgh Institutional Review Board. On study completion, results will be published in the peer-reviewed literature and at ClinicalTrials.gov.Trial registration numberNCT06626334.

Background The benefit–risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O 2 ) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients. Methods The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO 2 /FiO 2 ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O 2 and “early” NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and “late” NIV, indicated in patients with respiratory deterioration and/or PaO 2 /FiO 2 ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS). Results Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20–2.43), p  =  0.60 . The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73–5.89], p  =  0.18, 0.85 [95%IC: 0.33–2.20], p  =  0.74 and 2.14 [95%IC: 0.36–20.77], p  =  0.41 , respectively). Conclusion A prompt association of HFNC-O 2 with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure. Clinical Trial Registration : NCT03943914, Registered 7 May 2019.

Introduction Bombings, accounting for approximately 50% of global terrorist incidents, frequently cause high-morbidity thoracic trauma, including blast lung injury. This retrospective radiological review characterizes injury patterns in bomb blast victims to guide mass casualty response and improve patient outcomes. Methods This retrospective observational review, conducted at Aga Khan University Hospital (January 2004–October 2024), included 130 patients with bomb blast injuries. Demographics, injury mechanisms, and imaging findings were categorized by blast type and summarized using frequencies, percentages, medians, and interquartile ranges. Results Among 130 victims (94.6% males; median (interquartile range) age, 32 (26.0–43.5) years), initial chest X-ray was performed in 85.4% of cases, detecting foreign bodies (22.8%), emphysema (10.4%), and atelectasis (10.4%). Computed tomography was performed in 28.5% of the patients on the second imaging assessment; however, foreign bodies and atelectasis persisted at 14.4%–15.9% on follow-up. Primary blast injuries predominated (68.4%–78.8%), followed by secondary (15.0%–23.3%), tertiary (0%–4.7%), and quaternary (1.8%–4.4%) injuries; additionally, 48.5% of patients did not undergo a third study. Conclusions Primary blast injuries predominate, with frequent foreign bodies, emphysema, and atelectasis. Initial chest X-ray facilitates rapid assessment, while computed tomography is reserved for complex cases. Tailored imaging protocols may enhance timely care and outcomes in resource-limited settings.

Introduction Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. Methods Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t -test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P  < 0.05. Results Forty-three patients were enrolled. Baseline characteristics between PC patients ( N  = 20) and CT patients ( N  = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P  = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P  = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P  = 0.001). Conclusion In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434

IntroductionTraumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician’s discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces.Methods and analysisThe CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months.Ethics and disseminationThis trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberISRCTN35574247.

Older adults represent a growing proportion of motorcyclists and experience poor outcomes after crashes, but the role of frailty has not been characterized. We hypothesized that certain injuries and adverse outcomes would be more common with frailty. The Trauma Quality Improvement Program database was retrospectively reviewed for patients aged ≥50 years with motorcycle collisions from 2017 to 2021. Injury patterns were compared by frailty status and multivariable regression assessed the effect of frailty on mortality and adverse discharge. Among 58,149 patients, 14.9 ​% were frail. Frail patients sustained fewer lower extremity injuries but had higher rates of chest injury. Frailty was associated with mortality (aOR 1.31, 95 ​% CI 1.13–1.51) and discharge to healthcare facilities (aOR 1.52, 95 ​% CI 1.43–1.62). These findings highlight opportunities for integrating frailty screening into motorcycle rider education and support the promotion of chest protection, such as protective vests, for older, frail riders. [Display omitted] •Frailty in older motorcyclists predicted mortality and adverse discharge.•Frail riders had more rib fractures and severe chest trauma.•Findings support frailty screening and chest protection for older, frail riders.

PurposeTube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT.MethodsProspective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation.ResultsSixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5 days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications.ConclusionsThe use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.