Asian Cardiovasc Thorac Ann 1998;6:308-312
© 1998 Asia Publishing EXchange Pte Ltd
Blunt Thoracic Trauma: Analysis of 1730 Patients
Cemal Kahraman, MD,
Kutay Ta
demir, MD,
Yi
it Akçali, MD,
Fahri Ouzkaya, MD,
Naci Emiroullari , MD,
Mehmet Bilgin, MD
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Department of Thoracic and Cardiovascular Surgery Erciyes University Medical Faculty Kayseri, Turkey
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For reprint information contact: Cemal Kahraman, MD Mustafa Kemal Paa Bulvari Hakan Sitesi No. 23 Kayseri 38010, Turkey Tel: 90 352 437 4242 Fax: 90 352 222 3272
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ABSTRACT
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Between 1978 and 1997, 1730 patients with blunt thoracic trauma were treated in our department. There were 450 females and 1280 males. The mean age was 34.3 years ranging from 2 months to 80 years. The most frequent causes of trauma were motor vehicle accidents in 1438 patients and occupational accidents in 232. Injury to multiple intrathoracic structures was noted in 986 (57%) cases. There were associated injuries to the abdomen (13.76%), the head (23.35%), and the skeletal system (22.6%). Eighty-nine percent of the blunt thoracic traumas did not require open thoracotomy but immediate use of lifesaving measures such as closed tube thoracostomy for hemothorax or pneumothorax was necessary in 1543 cases. A laparotomy was carried out in 238 patients. The most common blunt thoracic traumas requiring immediate thoracotomy were massive hemothorax (33 cases), cardiac tamponade (2 cases), and massive tracheobronchial air leak (24 cases). Surgical intervention was necessary in 22 patients with diaphragmatic rupture and in 5 patients with isolated sternal fractures. During the posttraumatic period, adult respiratory distress syndrome occurred in 71 patients, pleural thickening in 29, and pleural empyema in 21 patients. The most common causes of morbidity were atelectasis (10.06%) and pneumonia (5.32%). The mean hospital time for all patients was 15 days and the mortality rate was 5.61%.
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INTRODUCTION
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Blunt thoracic trauma is seen frequently and it is one of the major injuries resulting in death in younger people. Approximately 20% to 25% of traumatic deaths are caused by isolated thoracic trauma.1 Twenty-five of every 100,000 trauma victims die following the trauma.2 Associated organ injuries raise the mortality. Close observation of vital signs and serial chest radiographs are essential in monitoring such patients. Sometimes they may need tube thoracostomy for effective treatment. Hemodynamically unstable patients with cardiac and great vessel injuries, tracheobronchial or diaphragmatic rupture may need urgent surgical intervention.1–3 The most serious pathologies that affect mortality in isolated thoracic traumas are pulmonary contusion and flail chest.4 Posttraumatic respiratory failures can be corrected with ventilatory support and clinical observation.1,5
Nearly 20% of fatal-trauma victims die at the scene of the accident. Therefore, early effective intervention at the accident site by qualified personnel with the necessary equipment as well as early transportation of victims can obviously reduce morbidity and mortality to a considerable degree. In addition, public education and provision of appropriate road conditions are of paramount importance in preventing accidents.
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PATIENTS AND METHODS
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In our department, 1730 patients with blunt thoracic trauma were treated between 1978 and 1997. The ages of these patients ranged from 2 months to 80 years with a mean of 34.3 years and 1280 (74%) were male. The causes of injury are summarized in Table 1
. Diagnostic methods employed during the initial assessment and treatment in the emergency room included physical examination, chest radiography, arterial blood gas analysis, electrocardiography, paracentesis, tube thoracostomy, connection to an underwater seal, and intravenous fluids. After resuscitation, patients who underwent surgery were followed up in the intensive care unit.
During intensive care, vital functions, arterial blood gases, hematocrit, arterial and central venous pressures, and daily chest radiographs were monitored meticulously. Respiratory support was supplied when necessary as indicated by arterial blood gas analysis. Patients with rib fractures were anesthetized epidurally or intercostal nerve blockade was performed. In patients with abdominal injuries, analgesics were avoided until a conclusive diagnosis was made. Massive intrathoracic hemorrhage or air leakage, cardiac tamponade, diaphragmatic rupture, sternal fracture, and vascular injuries were indications for emergency thoracotomy. Ultrasonography and angiography were performed when necessary. In the presence of pulmonary contusion, prophylactic treatment was provided to avoid adult respiratory distress syndrome (ARDS).
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RESULTS
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Apical or basal chest tube drainage and medical treatment yielded a successful outcome in 89.2% of the patients with intrathoracic injuries. Ninety-one (5.3%) patients underwent emergency surgical intervention for their intrathoracic injuries, 33 of these had active hemorrhage, 24 had massive air leakage, and 2 had the evidence of cardiac tamponade. Surgical intervention was necessary in 27 patients with diaphragmatic rupture and in 5 patients with isolated sternal fractures.
Bronchial rupture was observed in 14 of the patients with massive air leakage; 9 bronchial injuries were localized on the right side and 5 were on the left. The right main bronchus was disrupted completely in 2 cases, another had a membranous laceration between the left main bronchus and the upper lobe bronchus. The other bronchial wounds were located in the lobar bronchus. One of the patients with bronchial rupture underwent lobectomy for the accompanying parenchymal laceration, the rupture in the other one was repaired using primary sutures (Figure 1). There was no mortality in this group.
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Figure 1. Chest radiograph demonstrating hemopneumothorax and main bronchus rupture ("falling lung sign") in the right hemithorax.
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Three patients required lobectomy for diffuse parenchymal damage. Cardiac injuries were located in the right ventricle in one patient and in the right atrium in the other 2. There were no cases of transected aorta. Intrathoracic complications resulting from thoracic trauma are presented in Table 2. Two patients died intraoperatively. A diagnosis of diaphragmatic rupture was made intraoperatively in 5 patients and by further investigation in the other patients on suspicion of diaphragmatic rupture because of an unusual appearance in their chest radiographs. Ruptures were in the right side in 3 patients and in the left hemidiaphragm in 24 patients. Defects were repaired using nonabsorbable suture material and an interrupted suture technique. In one patient, ductus thoracicus injury was seen intraoperatively and it was ligated using Teflon pledgets with nonabsorbable suture.
Bony thorax pathologies are presented in Table 3. Fractures of the 1st and 2nd ribs were detected in 47 cases (Figure 2). A brachial plexus lesion was found in 4 of these patients. Flail chest and sternal fractures were observed in 96 and 29 cases respectively. Sternal fracture was in the manubriosternal joint in 2 cases. The number of patients with intrathoracic injuries but without fractures was 169. Pulmonary contusion, diagnosed by locating acute infiltration in the initial chest radiograph, was observed in 84 patients with bilateral involvement in one patient and from 1 to 3 lobes in the others.
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Figure 2. Chest radiograph demonstrating clavicular and multiple rib fractures in the right hemithorax.
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ARDS developed in 30% of the patients with pulmonary contusion. The causes of ARDS were multifactorial and included pulmonary contusion, pneumonia, extrathoracic trauma, shock, aspiration, and disseminated intravascular coagulation. Patients who had pulmonary contusion (30%), pneumonia (19.5%) or extrathoracic trauma (2%) were at the highest risk of developing ARDS.
Perthes syndrome was seen in 24 patients, resulting from thoracic compression in vehicle accidents in 20 cases and from falling from a high place in 4. Epilepsy developed in one of these patients. Tracheostomy was necessary in 15 cases to facilitate removal of secretions. Two hundred and thirty-eight (13.76%) patients were operated on for their accompanying intra-abdominal injuries (liver laceration in 78 and splenic laceration in 161). Advanced renal damage was seen in 5 patients, one requiring nephrectomy since the right kidney had been detached from its hilus and moved through the ruptured diaphragm to the right hemithorax. Table 4 shows the other traumas accompanying thoracic traumas. Cranial trauma was present in 404 patients with paraplegia developing in 19. Mechanical ventilation was necessary in 102 patients with a mean duration of 10 days. Five patients died due to sepsis during mechanical ventilation. During the posttraumatic period, ARDS occurred in 71 cases, pleural thickening in 29, pleural empyema in 21, and abscess formation in 3 patients. The most frequent of these were atelectasis (10.06%) and pneumonia (5.32%); 24 patients with pleural thickening and 3 patients with fibrothorax underwent early thoracotomy (Table 5). Pleural thickening developed as a result of traumatic empyema due to hemothorax.
The mean hospital stay for all the patients was 15 days and the mortality was 5.61% (Table 6). Hypovolemic shock in the early period in 6 patients, respiratory failure in 5 patients, and cerebral contusion in 14 patients resulted in death. ARDS was the main cause of death in the late period of trauma.
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DISCUSSION
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Trauma is the leading cause of death among people younger than 40 years of age. Twenty-five in every 100,000 people die annually of thoracic trauma.2 In cases of thoracic trauma, 20% of patients die on their way to hospital.1 The two most common causes of death between the accident site and the casualty department are respiratory distress and irreversible hypovolemic shock, which in our series accounted for the deaths of 11 patients in spite of all efforts.3 Effective and urgent intervention after accidents and close observation of vital signs were lifesaving in our experience, where 35 patients were in hypovolemic shock on arrival. Early thoracotomy saved life in 33 cases but 2 patients died because of irreversible hemorrhagic shock. Emergency thoracotomy in blunt traumas is still a controversial issue.2,3 Urgent left thora-cotomy is indicated for all patients who are not responsive to effective resuscitation. Those with no vital signs on monitoring or after the first 30 minutes following the trauma may not require resuscitation, although it is advisable for reasons such as lack of information. The most frequent findings in blunt thoracic trauma were pneumothorax and hemothorax. These complications can be treated successfully by tube thoracostomy, as in 91.3% of the patients in our series. The decision for a thoracotomy can also be made by examining the blood gas analysis of a hemorrhage. If the PO2 of the drainage is equal to or higher than the blood PaO2, it is highly likely that the bleeding is of arterial origin. However, in the presence of accompanying pneumothorax, this finding may be misleading.6 In order to prevent complications during the posttraumatic period, it is mandatory to relieve pain, which is most effectively achieved with epidural anesthesia or intercostal nerve blockade, and to provide adequate respiration. Seventy-two hours after trauma, the need for regional anesthesia will diminish and pain can be adequately relieved with parenteral morphine sulphate or oral codeine. Our patients underwent either of these anesthetic procedures.
Intra-abdominal pathologies may be observed in the lower thorax or upper abdomen as a result of blunt thoracic traumas or falling from a high place.7–9 Intra-abdominal injury accompanied thoracic traumas in 15.5% of the patients in our series. Such injuries can be missed because of severe chest pain. Therefore, the patients should be repeatedly assessed for possible pathologies. Two cases of suspected hemothorax were operated on and nothing abnormal was detected in spite of intra-abdominal bleeding that passed into the thorax through the ruptured diaphragm.
Pathologies occurring during trauma are often seen in the bony thorax. Radiologic examination revealed rib fractures in 1442 (83.4%) and clavicle fractures in 71 patients. Flail chest was observed in 96 of our patients with rib fractures. Emergency treatment of flail chest is controversial but most of such patients can be treated conservatively. However, open fixation of flail segments is the necessary course of action in cases such as impairment of stability in a large segment of the thoracic wall, loss of pulmonary function in spite of ventilation, serious restriction of the ability to move due to pain, and other respiratory complaints.1,4 This procedure not only corrects the deformity and restores pulmonary function but also shortens ventilation time and relieves pain. We performed open fixation on 2 patients for these reasons. Sternal fracture occurred at a rate of 1.68% in our series but other authors have reported a rate of 4%.10 Our relatively low figure can be ascribed to the Turkish drivers' negligence in using seat belts. First and 2nd rib fractures occurred in 47 patients, of whom 4 developed brachial plexus injuries.
Tracheobronchial rupture is multifactorial. Rapid deceleration or compression may give rise to ruptures in fixed regions such as the carina and cricoid cartilage, and a sharp increase in the intrabronchial pressure may lead to bronchial rupture. Bronchial rupture occurred in 13 patients requiring urgent surgical intervention; rupture of the cervical trachea in one case required tracheostomy.
Pulmonary contusion, tracheobronchial rupture, diaphragmatic rupture, and cardiac contusion, which are very common in children, were seen in 23 patients in our series. Since the thoracic cavity in children has a greater ability to resist compression, pulmonary pathologies can develop without rib fractures.11 Pulmonary contusion can resolve within a week unless infection occurs.12 However, there are many risk factors in patients with multiple traumas, which contribute to the development of infection in the posttraumatic period, such as atelectasis, pulmonary contusion, tracheostomy, endotracheal intubation, and aspiration.12 Pneumonia occurred in 31 patients with pulmonary contusion in our series and they responded to treatment. An abrupt rise in the pressure of the venous system due to compression of the thorax and abdomen may result in subconjunctival hemorrhage and ecchymotic lesions in the face and neck, a usually benign condition called Perthes' syndrome.13 This condition was observed in 24 of our patients, one of whom developed epilepsy.
Diaphragmatic ruptures can occur as a result of blunt or penetrating injuries to the lower chest and upper abdomen.9 They are usually missed in the early period after blunt trauma. Diagnosis can be made with further investigation upon suspicion; suspicion was confirmed in 22 of 27 patients in our study.8
Cardiac injuries rank highest for mortality among thoracic traumas. Since most of such victims die at the place of the accident, only a small proportion reach hospital.14 Diagnosis can be difficult in some patients with multiple traumas and the possibility must be kept in mind. Urgent thoracotomy is indicated if cardiac arrest has occurred on arrival and more than half of the patients in this condition can be saved.14 Signs of pericardial tamponade were seen in 2 of our patients on arrival; urgent surgery was carried out to repair the right ventricle in one and the left atrium in the other.
We performed a lobectomy in 4 patients with disseminated parenchymal damage and decortication in 24 patients with fibrothorax or pleural thickening due to inadequate drainage. The timing of decortication was consistent with the criteria adopted by the authors for early decortication.1,15,16 The mortality rate in our series (5.61%) was below the reported rates of 7.7% to 14%.1,8,16 The principal factors affecting mortality were flail chest, pulmonary contusion, and associated cranial trauma.
Trauma, principally from traffic accidents, is responsible for thousands of deaths and handicaps every year. The number can be minimized only through better driver training and awareness of the risks of speeding as well as by providing motorways of a high standard. A great responsibility falls on mass-media organisations in this respect. Success in treatment, however, can be increased with initial effective intervention at the site of the accident by personnel qualified in traumatology and appropriately equipped, as well as by transport of the patient to hospital within the shortest possible time.
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ABSTRACT
INTRODUCTION
