Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood. In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2-3 days (Group 1), 4-6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups. The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference. This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.

Background Blunt chest injuries are usually combined with multiple rib fractures and severe lung contusions. This can occasionally induce acute respiratory failure and prolong ventilations. In order to reduce the periods of ventilator dependency, we propose a less invasive method of fixing multiple rib fractures. Methods Since October 2009, we have developed a new method to fix fractured ribs caused by blunt trauma. Rib fixations were performed using 2.0- or 2.5-mm intramedullary titanium elastic nails (TEN), with the help of video-assisted thoracoscopic surgery (VATS) and minimal thoracic incisions. All the patients’ demographics and postoperative data were collected. Results From January 2010 to December 2012, a total of 65 patients presenting with multiple rib fractures resulting in acute respiratory failure were included in the study. Twelve patients received the new surgical fixation. Rib fixations were performed at an average of 4 days after trauma. Patients were successfully weaned off ventilators after an average of 3 days. The average length of stay in the hospital and the intensive care unit (ICU) was shorter for the patients with fixation than for nonsurgical patients. All twelve patients returned to normal daily activities and work. Conclusions In the reconstruction of an injured chest wall, the VATS with TENs fixation in multiple rib fractures is feasible. This method is also effective in decreasing the length of the surgical wound. Because the structure of the chest cage is protected, the period of mechanical ventilation is shortened and the length of stay in the hospital and the ICU can be reduced.

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 discharged (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.

Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%,P=0.061) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27,P=0.029) and in the hospital (15.93 versus 23.17,P=0.01) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS.

We read the article “Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis” by Natthida Owattanapanich et al. with great interest and found it to be insightful. In our commentary, we propose possible reasons why mortality was lower in the permissive hypotension group and how the need for blood transfusion decreased in this group. No significant difference in acute kidney injury (AKI) was evident among patient groups, possibly because all these patients might have AKI. However, we do agree that permissive hypotension is of considerable benefit to trauma patients and worth further study.