Possible failure to transfer to trauma center for trauma involving chest injuries with resultant death due to pulmonary decompensation and arrest.

This unfortunate case is exactly why trauma institutions exist. Motorcycle accidents present a clinical situation unlike many other traumatic injuries. More often than is appreciated the pulmonary contusions in these types of accidents are far worse than is typically evident at the time of the initial presentations. These contusions tend to worsen over a 48-72 hour period (much like any bruise evolves) and peak in the subsequent days. Very similar to the presentation described. If one is not aggressive in the initial care/oxygenation, fluid management etc of the patient these can be made much worse or at best not improved during the initial 48-72 hours. This care if done properly can mitigate the clinical impact. It is very unlikely that a non-trauma center will have provided this care, though I would have to review the full records to confirm. There is a second error in that a euroseal is not adequate care in this situation. It will not fully evacuate the blood (a hydropneumothorax is a hemopneumothorax until proven differently in the setting of trauma). Blood is not well evacuated via that system and requires a larger bore chest tube which the patient didn't receive until several days later. By this time the blood likely clotted and will not evacuate with a chest tube but now requires thoracic surgery. This will trigger further inflammatory response. I would need to review the entire record but the information provided is deeply troubling.

As above, there are likely at least two possibly more errors. This patient should have been transferred to an institution that manages these injuries more frequently and thus would recognize the problems sooner and handle them more effectively. Also, the initial chest drainage was inappropriate. These combined factors even alone can lead to the outcome described, in conjunction is worse.

Patient probably required intubation to decrease work of breathing. Broncoscopy also could have been facilitated and performed after intubation. Good possibility of significant bronchial injury and hemothorax that necessitated thoracotomy/ bronchial repair or resection. Possibly also, patient may have benefited from rib stabilization surgery with thoracotomy.

Sounds as though he was neglected, inappropriately under assessed and mistreated.He should have been transferred based on mechanism, initial stability and degree of chest injuries. He should have been aggresively managed and followed by thoracic or trauma surgeons.

Euroseal devices are not adequate in draining a pneumothorax in the presence of significant chest wall injury and hemothorax. This patient should have been transferred to a higher level of care

There seem to be a delayed diagnosis regarding the real cause of the pneumothorax and penumomediatimun, it could be a large airway injury or even an esophageal injury. Based on the information provided, these were not ruled out with a bronchoscopy or esophagoscope

The initial management of blunt chest trauma with a closed suction drain is appropriate. However, the challenge comes when that initial management is insufficient or the patient's course begins to deviate from the expected trajectory. That's the value of having somebody at a dedicated trauma center -- the team at a trauma center can recognize when things are not going according to plan. For providers who do not deal with much trauma, subtle signs may be missed, leading to potentially catastrophic outcomes as here. Once the patient had a second CT with worsening findings and needed another chest tube, that was an indication that his course was not straightforward and he should have been at a specialized center. By the time of the second CT chest, the patient had developed pneumomediastinum. That's concerning and warrants more investigation. The following day the chest tube has a new air leak. This needs to be interpreted as worsening of the pulmonary injury, potentially something as disastrous as a bronchial disruption. There could have been pulmonary contusion that lead to ischemia of the bronchi and eventual breakdown of the bronchi and massive air leak. Whatever the cause, the development of a new air leak can herald a disaster, and the patient should have been urgently transferred to a trauma center then if not earlier. Even radiology is important: In this case, the CT is read as "pleural effusion." In the setting of trauma with rib fractures, that is blood -- it's a hemothorax. The radiologist's report may have provided the clinician with a false sense of confidence. Radiologists who interpret numerous trauma films may have been clearer that the fluid is likely to have been blood.

If the patient had been at a trauma center, he may have undergone further evaluation of his pneumomediastinum, had a thoracic surgeon involved, or undergone surgery to evaluate his worsening pulmonary injury. The severity of his injury may have been diagnosed and managed before he coded

This patient had blunt chest wall trauma - this is a survivable injury. The fact is that the extent of trauma should not lead to mortality. When the patient had the repeat CT scan, the patient should have been admitted to the ICU. The fact that there is an air leak, increasing gas, and the development of pneumomediastinum, there is a high likelihood of a missed bronchial injury. Thoracic surgery should have been consulted for bronchial repair. Despite more chest tubes, the 40-year-old patient continues to deteriorate and ultimately expired.

This patient should have been admitted to the icu of a verified trauma center with thoracic surgery capabilities. The patient had complex blunt thoracic trauma - most commonly is not life-threatening unless an injury is left unaddressed.

This patient had a complex chest wall injury. He likely should have initially been upgraded to a trauma center and bypassed this hospital by EMS. This however, depends on the location, distance from a trauma center and resources available to EMS. This patient was worked up appropriately in the emergency department, however, he had indications for a chest tube placement at this time. This is the first clinical error - he should have had a chest tube placed at this time. On 7/4, the chest CT is even more concerning with the pulmonary contusions and pneumonitis. At this point, the pneumomediastinum is very concerning. The idea to place a chest tube at this time is correct, but there is no workup for an esophageal or bronchial injury, which is suspicious. Its unclear to be if the patient died from overwhelming sepsis, or from an unrecognized bronchial injury that opened up and the patient was unable to be ventilated - I would need to see more complete medical records. In any case, this patient belonged in a trauma center. All ED physicians are required to take Advanced Trauma Life Support at least once in their career. In this course, the American College of Surgeons Interhospital Transfer Criteria is reviewed, which states that one criteria for transfer to a trauma center is major chest wall injury or pulmonary contusion. This patient clearly had pulmonary contusions and should have been transferred, or even taken to a trauma center by EMS and bypassing the original facility. https://www.tomwademd.net/advanced-trauma-life-support-atls-interhospital-transfer-criteria/

This patient required tertiary level care provided at a trauma center. The continuation of care at a less sophisticated medical center without specific expertise in multiple blunt trauma is an error in management. There was clearly a missed diagnosis somewhere - its unclear what that missed diagnosis is, although it may be available on a postmortem examination.