Asian Cardiovasc Thorac Ann 1999;7:124-127
© 1999 Asia Publishing EXchange Pte Ltd
Profile of Chest Trauma in a Referral Hospital: A Five-Year Experience
Raju S Iyer, MCh,
Padmanabhan Manoj, MCh,
Rajnish Jain, MD,1,
Prasad Venkatesh, MD,1,
Dronamraju Dilip, FRCS
Department of Cardiothoracic Surgery
1 Department of Anaesthesia
Sri Venkateswara Institute of Medical Sciences
Tirupati, Andhra Pradesh, India
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For reprint information contact: Raju S Iyer, MCh Tel: 91 422 21 1000 Fax: 91 422 21 3509 email: gknmh{at}vsnl.com G Kuppuswamy Naidu Memorial Hospital, Department of Cardiothoracic Surgery, P. O. Box 6327, Pappanaickenpalayam, Arinashi Road, Coimbatore, Tamil Nadu 641037, India.
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Abstract
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From April 1993 to March 1998, 90 patients with chest injuries were retrospectively assessed for the incidence, presentation, and outcome of thoracic trauma. The majority (55.6%) were less than 40 years of age and 83 (92%) were male. The mode and extent of injury, specific intrathoracic organ injuries, associated injuries, flail chest, ventilatory requirements, management, morbidity, and mortality were analyzed. Blunt injuries were seen in 56 (62.2%) and penetrating injuries in 34 (37.7%). Multiple rib fractures with hemopneumothorax was the most frequent presentation with orthopedic and head injuries being most commonly associated. Patients with tachypnea, cyanosis, lung contusion, partial pressure of aterial oxygen less than 60 mm Hg, and those with more than 6 rib fractures most often required ventilation but the majority (54.4%) were treated with a chest drain only. Emergency or delayed thoracotomy was required in 24.4%. The mortality rate was 6.7%, mainly due to respiratory insufficiency. Subcutaneous emphysema requiring releasing incisions accounted for most of the morbidity. Mean hospital stay was 9.5 days. Chest injuries were of major concern in multisystem trauma patients and early planned management is recommended in a mostly vulnerable section of our population in an age of violence and vehicular accidents.
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Introduction
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The incidence of chest trauma has increased significantly over the last 100 years as a result of the development of rapid means of transport and the rising level of violence in society in general.1 Medical personnel who care for patients with thoracic trauma should understand the risks of mortality and clinical deterioration as well as associated injuries. The aim should be to restore normal cardiorespiratory function, control bleeding, treat associated injuries, and prevent sepsis. Conditions affecting primarily extrathoracic sites may also have an indirect effect on the lungs, causing adult respiratory distress syndrome.2 The chest wall, consisting of ribs, sternum, clavicles, and scapulae, affords protection to the underlying viscera but serious intrathoracic injuries may be present even in the absence of obvious chest wall injury. Care must be taken to avoid underestimation of the effect of the injury on respiratory mechanics. With a better understanding of emergency requirements and use of a team approach to provide anesthesia, surgery, and critical care, the trauma victim with chest injury receives better care with a consequently better outcome. This study was undertaken to assess the pattern and incidence of trauma, nature of chest injuries, management, and outcome.
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Patients and Methods
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All patients with chest trauma with or without associated injuries, admitted to our emergency department between April 1993 and March 1998, were included in this study. The injuries were classified as blunt (inclusive of injuries without loss of skin continuity) or penetrating. These were grouped according to the cause: fall; vehicular accident; blunt assault; stab injury; bull gore injury; or gun shot wound. Associated injuries, specific intrathoracic organ injuries, and pathology were noted. Patients requiring ventilation were studied with respect to flail chest, tachypnea, cyanosis, blood gas analysis, rib fractures, surgical procedure, and intrapleural pathology.
Surgical exploration was analyzed with respect to indication. Outcome was denoted as death, morbidity, or total cure. Morbidity included release incisions for subcutaneous emphysema, wound infection, hemoptysis, persistent air leak, and pneumonia. The length of hospital stay was tabulated at intervals of 5 days. Flail chest was defined as paradoxical movement of the chest wall with associated rib fracture, with or without altered clinical and blood gas parameters. Criteria for ventilatory support were identified.
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Results
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The incidence of chest trauma among all trauma cases admitted to this hospital during the 5-year study period was 9% (90/1000). Of these 90 patients, 83 (92%) were male and 7 (8%) were female. The majority (55.6%) were less than 40 years of age with 10 (11.1%) less than 20 years old, 40 (44.4%) in the age range 21 to 40 years, 12 (13.3%) between 41 and 60 years, and 28 patients (31.1%) over 60 years old.
Blunt injuries, mostly resulting from falls and vehicular accidents, were seen in 56 patients (62.2%). Penetrating chest trauma occurred in 34 patients (37.8%), with stab and bull gore injuries being the most common. Fractures of the clavicle or long bones were seen in 19 (21%) and associated head injuries were found in 9 patients (10%). Associated abdominal injury, neurovascular injury, and contused lacerated wounds occurred in 3 cases each (3.3%). Multiple rib fractures were noted in 51.1% of patients with 35.6% having hemopneumothorax. Other thoracic injuries are shown in Table 1
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Thirteen patients (14.4%) required ventilation, of whom 5 had flail chest. Six patients with flail chest did not require ventilation. The other 8 patients needed ventilatory support because of respiratory insufficiency with tachypnea, abnormal blood gases, lung contusion, or surgical procedures (Table 2). Forty-nine (54.4%) were managed by chest drain alone and 19 (21.1%) did not require any invasive procedure.
Twenty-two patients (24.4%) underwent exploratory thoracotomy that was performed on an emergency basis in 18 (81.1%). Surgical management is detailed in Table 3. Of the 5 patients explored for lung injury, 2 required lobectomy, 2 underwent segmental resection, and one needed suture closure of a major bronchial air leak. Of the 4 cardiac injuries, a right ventricular tear was seen in 2 cases and there was one left ventricular tear and one right atrial tear. The vascular injuries found on exploration included one each to the ascending aorta, right internal mammary artery, right internal jugular vein, and the subclavian vein.
Six (6.7%) patients died from various causes (Table 4), of which respiratory insufficiency resulting from adult respiratory distress syndrome and lung contusion accounted for half of the mortality. Ten patients with massive subcutaneous emphysema required releasing incisions. Wound infection occurred in 4 patients. Two patients with pneumonia had a prolonged hospital stay requiring antibiotics and physiotherapy. One patient with a persistent air leak was treated by chemical pleurodesis (tetracycline) and one patient with hemoptysis required medical management and repeated bronchoscopies. The mean duration of hospital stay was 9.5 days (range, 2 to 40 days). Only 3 patients required a hospital stay of more than 3 weeks (Table 5).
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Discussion
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Chest trauma is an important cause of morbidity and mortality throughout the world. Although the overall survival rate has improved, deaths are often due to airway obstruction, hemorrhage, flail chest, tension pneumo-thorax, cardiac tamponade, and associated intra-abdominal and skeletal injuries. This study was carried out to assess the incidence and pattern of chest trauma in this part of the country and to provide information for prioritizing the injuries, thus improving our trauma care system. Although less than 15% of patients with chest trauma require surgical intervention, many needless deaths may occur due to inadequate or delayed treatment.
Males predominated in our study probably because of their more mobile lifestyle and use of high-speed vehicles. The most vulnerable age group was 21 to 40 years, in which there was a higher incidence of trauma due to assault. Injury to the chest in patients over 60 years of age was caused by a fall in more than 70% of cases. Blunt chest trauma was due equally to vehicular accidents and falls. Assault accounted for only 2.2% of chest traumas, mainly penetrating chest injury. Surprisingly, bull gore injury constituted a major proportion of the chest traumas, indicating that this population was mostly from a rural community. Vehicular accidents resulted in more blunt (28.8%) than penetrating (5.5%) chest traumas. This experience highlights the importance of the anesthe-siologist in airway management, stabilization of hemo-dynamics, critical care, and intraoperative management.3
Of the specific intrathoracic injuries, multiple rib fractures were most common with over 90% resulting in hemothorax, similar to the findings of Locicero and Mattox4. The diagnosis was clinical rather than radiographic, with pain on respiration and tenderness on palpation. A very low threshold should be adopted for chest tube placement in cases of hemothorax because blood in the chest increases the risk of empyema with loss of lung function. Delay in placement of a chest drain allows the blood to clot, making later attempts at drainage more difficult.5 Of the 13 patients requiring ventilatory support, only 5 had flail chest, indicating that lung contusion rather than altered mechanics was the major factor causing a need for ventilation. This was supported by the fact that 6 patients with flail chest did not require ventilation. However, flail chest can serve as a marker of significant intrathoracic injury associated with pulmonary contusion. Without marked derangement of the basic pulmonary architecture, the contused lung is more amenable to the sequestration of fluid that leads to adult respiratory distress syndrome.6
The fact that the majority of our patients were managed by chest drain alone emphasizes the usefulness of tube thoracostomy that can be a lifesaving and versatile monitoring technique, affording a margin of safety for patients in the emergency room.7,8 Of the 22 patients needing surgical management, 18 underwent emergency thoracotomy. All 4 cases of cardiac injury needing exploration were due to penetrating trauma and 3 were in the right side. The pressure in the right side is lower than that in the left so these injuries are more likely to be tamponaded, allowing such patients to reach the hospital alive. Exploratory thoracotomy was performed for early evacuation of hemothorax when chest drainage was more than 300 mL in the second hour. No lung resection was carried out in these cases. This is comparable to a study by Graham and colleagues.9 Two of our patients had a delayed thoracotomy for diaphragmatic injury, one of whom was referred from another center. An interesting case involved penetrating injury to the ascending aorta where the patient arrived in shock with tamponade. At surgery, the tear was found to be occluded by a clot and the rent was repaired under finger control. Of the 6 deaths, 3 were due to respiratory insufficiency. The contused lung responds to fluid resuscitation by filling the interstitial spaces and alveoli with proteinaceous fluid; arteriovenous shunting occurs and blood gas status deteriorates.10 No patient who underwent surgical exploration died.
The prime cause of morbidity was the need for releasing incisions in the chest for massive subcutaneous emphy-sema impairing respiration. Wound infection, resulting in delayed discharge from the hospital, mainly affected traffic accident victims who sustained a high degree of contamination at the site of the accident. Contusion of the lung leading to pneumonia, prolonged the hospital stay in 2 cases. Persistent pain leads to atelectasis and hypoventilation, predisposing to pneumonia that can cause hypoxemia, hypoventilation, carbon dioxide narcosis, and respiratory arrest. It has been our practice to employ a thoracic epidural catheter for injection of tramadol hydrochloride (100 mg twice daily) for postoperative analgesia and early extubation. Thus, adequate pain control, incentive spirometry, mobilization, and mechanical ventilation should be employed when necessary.
Our major conclusions from this study are that non-life-threatening blunt trauma is common and a low threshold for chest drain insertion should be adopted. Patients with penetrating chest wounds should always undergo exploratory thoracotomy as the majority have underlying organ injuries. Arterial pressure monitoring, avoidance of fluid overload, and oxygen therapy with or without mechanical ventilation are useful therapeutic guidelines in these patients. Those with continuous air leak or persistent drainage should undergo an open thoracotomy. Outcomes can be improved if appropriately trained hospital staff are available and priority given to chest trauma in a case of polytrauma, in addition to minimization of pre-hospital delays. Acute stabilization in the emergency room of a non-trauma-specialist hospital should be carried out before transportation to specialist centers, according to the Advanced Trauma Life Support protocols of the American College of Surgeons, as prompt institution of shock resuscitation can reduce many unnecessary deaths.11
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Abstract
Introduction
