Asian Cardiovasc Thorac Ann 2005;13:103-106
© 2005 Asia Publishing EXchange Ltd
Penetrating Chest Trauma in Nigeria
Martins O Thomas, FICS,
Ezekiel O Ogunleye, FWACS
Lagos University Teaching Hospital, College of Medicine of University of Lagos, Lagos, Nigeria
For reprint information contact: Martins O Thomas, FICS Tel: 234 1 791 7163 Fax: 234 1 583 1027 Email: oluwafemithomas{at}yahoo.com, Cardiothoracic Surgery Unit, Lagos University Teaching Hospital, College of Medicine of University of Lagos, Lagos, Nigeria.
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ABSTRACT
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Penetrating chest trauma occurs worldwide, and various accounts of it have been reported in the literature.1–5 Blunt trauma is not usually associated with military or civilian violence, while penetrating chest trauma often is. Penetrating chest trauma is frequently caused by gunshots and non gunshot-related incidents such as stabs, traffic accidents, and impalements. This prospective study was conducted to determine a pattern of penetrating thoracic injuries, including their causes, the role of surgery, and intervention outcomes. In this study, we treated 168 patients (142 males and 26 females, giving a male-to-female ratio of 5.5:1). Gunshots caused 60.1% of the injuries while traffic accidents caused 27.3% of the injuries. Chest tube insertion alone was the main treatment initiated. This technique was used on 73.8% of the patients. To reduce the occurrence of penetrating chest trauma in Lagos, Nigeria, study results suggest that the Nigerian people and their property need greater security, and that pre-hospital level of care for trauma victims must improve.
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INTRODUCTION
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Penetrating thoracic trauma (PTT) is a challenging problem, but fortunately most of these injuries can be managed non-operatively.1,2 Various accounts of PTT have been reported in the literature.2,3 In 710 chest trauma cases reported by Cakan and colleagues,3 72% were blunt injuries, while 28% were PTT. In 187 patients seen by Segers and colleagues,4 blunt trauma constituted 80.1% of the injuries, while PTT constituted 19.9%. The literature shows that blunt trauma is not commonly associated with war or civil strife, however penetrating trauma is.2,3 Males are more often the victims than females.4 Penetrating chest trauma is most often caused by gunshots and non gunshot-related incidents such as stabs, traffic accidents, and impalements.
Chest trauma management can be difficult, but the results are usually rewarding if appropriate steps are taken. Military surgical experience over the past several centuries has been important in the evolution of the clinical management of PTT.5
Although diagnosis of PTT is usually based on clinical and laboratory findings, diagnosing hemopneumothorax in PTT by physical examination alone is not sufficiently accurate.6 All victims of PTT require chest radiographs as many will have hemopneumothorax in the absence of clinical findings.6 It is generally agreed that most PTT patients can be treated by simple measures such as chest tube insertion only.2,3,4,6,7
The selection of patients for operation or observation can be made by clinical examination and appropriate investigations. Post-trauma ultrasound checks help rule out pericardial tamponade.1 Spiral computed tomography of the chest is used increasingly to evaluate trans-mediastinal gunshot wounds. Results can demonstrate the need for further organ specific tests such as esophagography, aortography, or bronchosocopy.1
The indications for surgical intervention include significant pneumothorax, hemothorax, hemopneumothorax, diaphragmatic injuries, pulmonary laceration, and great vessel injuries among others.4,8 The main indications for thoracotomy are major pulmonary laceration, aortic rupture, and diaphragmatic injuries.3,4
Major lung resections are required more often than previously reported, however "minor" resections, if feasible, are associated with improved outcomes. Consequently, trauma surgeons must be skilled in a range of technical procedures to manage lung injuries.9
The most frequent complication of chest trauma is atelectasis. Other potentially fatal complications range from exsanguination to adult respiratory distress syndrome.3–5 The general outlook of PTT is improving as better treatment and prevention of complications have greatly reduced morbidity.5 Although hospital mortality has fallen by a factor of ten since the mid-19th century, the total mortality caused by PTT has undergone less change.5
This prospective study was conducted to determine a pattern of penetrating thoracic injuries, including their causes, the role of surgery, and intervention outcomes.
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PATIENTS AND METHODS
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All patients with chest trauma who were brought to Lagos University Teaching Hospital in Nigeria between October 1996 and December 2002 were recruited into a prospective study examining the causes, pattern of injuries, and management outcomes of penetrating thoracic trauma. The protocol documented patients’ demographic data, clinical features, times and types of investigations and interventions, and management outcomes. We began treating the patients after an invitation from the on-duty casualty officers. All initial resuscitative measures were carried out on the spot. All operations including chest tube insertions were performed in the theatre as the hospital permitted.
We also documented concomitant injuries sustained, indications for surgery, and the management profile of the patients. The injury severity scores of the patients were documented after full assessment.
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RESULTS
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During the study, we saw 168 patients with penetrating chest injuries (Table 1
). Minor chest injuries (those that penetrated the chest wall only) accounted for 49 (29.2%) cases. The patients included 142 males and 26 females, giving a male-to-female ratio of 5.5:1. The age range was from 4 to 66 years. Of the injuries, 101 were gunshot injuries and 67 were non-gunshot penetrating injuries (Table 2). Injuries sustained during an armed robbery accounted for 77 (76.2%) of the gunshot cases. Traffic accidents caused 46 (68.7%) of the non-gunshot penetrating chest injuries
Those who had been shot had the highest injury severity scores (Table 3). Thoracotomy was performed in 27 patients (16.1%) and 124 patients (73.8%) were treated with chest tube insertion alone (Table 4).
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DISCUSSION
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Penetrating chest trauma is a challenging surgical problem worldwide.1–9 Our study’s figures may not be a true representation of Lagos’ cases because only a few ambulance services serve the metropolis. The Lagos State Government ambulances transport most accident victims to the city’s secondary health facilities. Even in the developed world, 10% of accident victims die before reaching a hospital.13
We treated 168 patients with penetrating chest injuries during the study’s five years, indicating an annual rate of about 34. The male preponderance of 5.5:1 is higher than the 2.9:1 found in Belgium in a retrospective analysis of 187 patients.4 A higher incidence of 7.7:1 was found in an Italian study with 191 cases.10 Most of the patients studied (n = 101, 60.1%) sustained gunshot injuries; 77 (76.2%) of those who had been shot sustained their injuries during an armed robbery attack.
The second greatest cause of injuries were traffic accidents, seen in 46 (27.4%) of the cases. No suicide cases were seen in any of the groups, including the gunshot group.
Minor to moderate chest trauma with an injury severity index of 50 and below was seen in 149 (88.7%) patients. The injury severity indexes (penetrating thoracic trauma index PTTI)11 were higher in gunshot cases than in the non-gunshot cases. Of the 14 patients who had PTT scores of 51 and above, only one survived. The remaining 13 died.
A thoracotomy rate of 16.1% was recorded in our study compared to 10.2% and 9.6% in the Belgian and Russian studies respectively.4,12 The difference may be due to the use of video-assisted thoracoscopic surgery in the Belgian and Russian studies, which may have reduced the thoracotomy rates. Such facilities are not available in Lagos.
Chest tube insertion alone was used to treat 124 (73.8%) of the patients (Table 5), a rate which conforms to worldwide trends.3,7,10 Ten patients received no treatment. Eight of these cases were due to misdiagnosis, and two were dead on arrival. The low mortality rate of 7.7% may be due to the fact that many patients died before reaching the hospital.
To reduce the occurrence of penetrating chest trauma in Lagos, Nigeria, study results suggest that the Nigerian people and their property need greater security. The pre-hospital level of care for trauma victims and services at the secondary and tertiary hospitals also needs improvement.
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REFERENCES
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- Demetriades D, Velmahos GC. Penetrating injuries of the chest: indications for operation. Scand J Surg 2002;91:41–5.[Medline]
- Kalyanaraman R, De Mello WF, Ravishankar M. Management of chest injuries – a 5 year retrospective survey. Injury 1998;29:443–6.[Medline]
- Cakan A, Yuncu G, Olgac G, Alar T, Sevinc S, Ors Kaya S, et al. Thoracic trauma: analysis of 987 cases. Ulus Trauma Derg 2001;7:236–41. Turkish.
- Segers P, Van Schil P, Jorens O, Van Den Brande F. Thoracic trauma: an analysis of 187 patients. Acta Chir Belg 2001;101:277–82.[Medline]
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- Bokhari F, Brakenridge S, Nagy K, Roberts R, Smith R, Joseph K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 2002;53:1135–8.[Medline]
- Thomas MO. Thoracic gunshot injuries in Lagos, Nigeria. Nig J Surg 2002;8:49–51.
- Adegboye VO, Ladipo JK, Adebo OA, Brimmo AI. Diaphragmatic injuries. Afr J Med Sci 2002;31:149–53.
- Karmy-Jones R, Jurkovich GJ, Shatz DV, Brundage S, Wall MJ Jr, Engelhardt S, et al. Management of traumatic lung injury: a Western Trauma Association Multicenter review. J Trauma 2001;51:1049–53.[Medline]
- Bergaminelli C, De Angelis P, Ganthier P, Salzano A, Vecchio G. Thoracic drainage in trauma emergencies. Minerva Chir 1999;54:697–702.[Medline]
- Ivatury RR, Nallathambi MN, Rohman M, Stahl WM. Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61–6.[Medline]
- Adebonojo SA. Management of chest trauma: a review. West Afr J Med 1993;12:122–32.[Medline]
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[Abstract]
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ABSTRACT
INTRODUCTION
