Cardiothoracic Trauma

EDITORIAL
	The First International Congress of the World Society for Cardiothoracic Trauma: Lessons learned	p. 1
	Moheb A Rashid DOI:10.4103/jctt.jctt_9_18
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	Controversies in cardiac trauma	p. 3
	Kenneth L Mattox DOI:10.4103/jctt.jctt_7_17
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ORIGINAL ARTICLES
	A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures	p. 5
	Helen Ingoe, Catriona Mcdaid, William Eardley, Amar Rangan, Catherine Hewitt DOI:10.4103/jctt.jctt_1_18   Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.
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REVIEW ARTICLE
	Blunt thoracic aortic injury	p. 11
	Tara Talaie, Jonathan J Morrison, James V O'Connor DOI:10.4103/jctt.jctt_7_18   Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.
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SURGICAL TECHNIQUES AND VIDEOS
	Tension pneumothorax: Are current techniques and guidelines safe?	p. 19
	Moheb A Rashid DOI:10.4103/jctt.jctt_5_18
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CASE REPORTS
	When bleeding wins clotting: The surgical dilemma in life-threatening hemothorax in hemophilia	p. 20
	Nisha B Jain, Sreekar Balasundaram, Joseph Sushil Rao DOI:10.4103/jctt.jctt_2_18   Due to the lack of awareness and poor access to laboratory diagnosis, hemophilia may not be diagnosed preoperatively leading to therapeutic misadventure during surgery. Hence, this congenital bleeding disorder due to Factor VIII deficiency reduces surgical management. We report a 39-year-old gentleman, diagnosed of Factor VIII deficiency who presented to emergency with acute spontaneous left hemothorax and underwent a successful thoracotomy and decortication which saved his life. He is positive for human immunodeficiency virus as well as hepatitis B for which he is on treatment. The management guidelines for thoracic surgery are not addressed to in the World Federation of Hemophilia guidelines, making the management challenging in this scenario. We report this case due to its rarity and emphasize that early recognition with immediate surgical intervention supported with Factor VIII transfusion played an important role in saving life.
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	Thoracic trauma by black caiman's bite in the Amazon region	p. 24
	João José Corrêa Bergamasco, Raquel Magalhães Pereira, Juan Eduardo Rios Rodriguez, Brígida Thaine Fernandes Cabral DOI:10.4103/jctt.jctt_3_18   Alligator attacks are rare, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. There are few reports of accidents by these animals. The reported species hereafter is the Melanosuchus niger from the Amazon rainforest. The patient aged 32 years, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite. Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite. Cases like this are not easy to conduct. Since the injury was on an atypical place, the severity of the symptoms was increased, leading to dyspnea and huge blood loss.
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IMAGES IN CARDIOTHORACIC TRAUMA
	The symptomless tension pneumothorax	p. 27
	Moheb A Rashid DOI:10.4103/jctt.jctt_6_18
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	Cardiac herniation into left pleural space and huge subcutaneous emphysema	p. 28
	Bruno José da Costa Medeiros DOI:10.4103/jctt.jctt_8_18
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