The risk factors and management of posttraumatic empyema in trauma patients
Introduction
Posttraumatic empyema (PTE) is a significant problem in both blunt and penetrating chest injuries. The incidence of PTE in patients who have sustained injuries to the chest has been reported to range from 2% to 25%.1, 5, 7, 9 Potential causes for PTE include iatrogenic infection of the pleural space during chest tube placement, direct infection resulting from penetrating injuries of the thoracic cavity, secondary infection of the pleural cavity from associated intra-abdominal organ injuries with diaphragmatic disruption, secondary infection of undrained or inadequately drained haemothoraces, haematogenous or lymphatic spread of subdiaphragmatic infection to the pleural space, and parapneumonic empyema resulting from posttraumatic pneumonia, pulmonary contusion, or acute respiratory distress syndrome.16
PTE causes an increase in the duration of hospitalisation, in morbidity and mortality rates, and in the cost of treatment. Therefore, a good knowledge of the risk factors for the development of PTE is necessary and measures should be taken to prevent it. The role of prophylactic antibiotics is controversial. In addition, risk factors that may independently predict PTE in patients with tube thoracostomy have not been elucidated fully. The aim of this study was to identify the risk factors for PTE and to review our treatment outcomes in patients with this condition.
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Patients and methods
Between January 1989 and January 2006, 2261 patients who underwent tube thoracostomy for thoracic trauma were treated in our Thoracic Surgery clinics. The hospital records of these patients were reviewed retrospectively. Clinical data including age, sex, type of injury, associated injuries, duration of tube thoracostomy, setting of tube thoracostomy placement, length of hospital and intensive care unit stay, lung and chest wall injuries, presence of retained haemothorax and exploratory
Results
The mean age of all patients was 37.2 ± 20.6 (5–78) years, and 1560 (69%) of the patients were males. The rate of PTE development was 4.0% (n = 34) in patients with penetrating thoracic trauma, and 2.6% (n = 37) in those with blunt thoracic trauma. This rate was 3.1% (n = 71) for all patients. Firearm wounds existed in 20 of the 34 (58.8%) patients with penetrating thoracic trauma who developed PTE, while the remaining 14 (41.2%) were wounded with sharp or piercing objects.
The most common associated
Discussion
The use of prophylactic antibiotics for the prevention of PTE after tube thoracostomy remains a controversial issue in the trauma literature. While a number of studies3, 4, 11, 15, 18, 22, 25 show favourable effects of prophylactic antibiotics in preventing PTE, several reports12, 14, 17, 20 have shown no benefit. The EAST Practice Management Guidelines Work Group concluded that there were insufficient data available to recommend routine use of prophylactic antibiotics in the management of tube
Conclusion
We determined that prolonged duration of tube thoracostomy and length of intensive care unit stay, and presence of contusion, laparatomy and retained haemothorax were independent predictors of PTE. Use of prophylactic antibiotics may be recommended only in patients with these risk factors. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo tube thoracostomy. Fibrinolytic therapy and thoracoscopy
References (26)
- et al.
Post-traumatic empyema
Ann Thorac Surg
(1977) - et al.
Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions
Chest
(1997) - et al.
Reevaluation of early evacuation of clotted hemothorax
Am J Surg
(1984) - et al.
Empyema thoracis in patients undergoing emergent closed tube thoracostomy for thoracic trauma
Am J Surg
(1989) - et al.
Prophylactic antibiotics in the treatment of penetrating chest wounds
J Thorac Cardiovasc Surg
(1977) - et al.
The role of thoracoscopy in the management of retained thoracic collections after trauma
Ann Thorac Surg
(1997) - et al.
Preventive antibiotic usage in traumatic thoracic injuries requiring closed tube thoracostomy
Chest
(1994) - et al.
Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis
Ann Thorac Surg
(1991) - et al.
Traumatic hemothorax: is decortication necessary?
J Thorac Cardiovasc Surg
(1979) - et al.
Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study
Am J Respir Crit Care Med
(1999)
The role of antibiotic therapy in prevention of empyema in patients with an isolated chest injury (ISS 9-10): a prospective study
J Trauma
Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy
Br J Surg
Empyema occurring in the multiple injured traumatized patient
J Trauma
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