Injuries of the chest*SD Deodhar, GB Pallod
Department of Surgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay 400 012, India
Thirty cases of chest injuries were admitted in the Department of Surgery, K.E.M. Hospital, Bombay. These injuries seem to be fairly common. Detailed examination at the time of admission is necessary to assess the clinical presentation and the presence of major complications. Institution of intra-peritoneal drainage, restoration of negative intra-pleural pressure and active respiratory physiotherapy constitute an important part of the treatment. The literature on this subject is briefly reviewed
Thoracic trauma either from road accidents, or from battle field, is a common surgical problem, ranging in severity from minor abrasion with fracture of a single rib requiring no treatment, to extensive disruption of the thoracic cage with concomitant injuries to multiple organs. The availability of many emergency measures, now enable the seriously injured, to survive the first few hours after sustaining major trauma; thus the physician and surgeon are afforded the opportunity to rehabilitate a large percentage of the injured.
It is the purpose of this presentation, to report our experience in the management of chest injuries.
We are presenting a study of 30 cases of acute chest injuries admitted to our unit, in K.E.M. Hospital, Bombay during the period, from 1st February 1977 to 30eth September 1977.
The total number of trauma cases during this period was 207, giving an incidence of 14.5%. The total number of admissions to our unit, during the same period, was 922, giving an overall incidence of 3.3%.
All the patients with wounds over chest wall and intrathoracic injuries, are included in this series; also included, are the patients with thoraco-abdominal injuries.
Twenty-nine patients were males and one female. The age ranged from 14 to 75 years, the average being 44.5 years. The majority of the patients belonged to age group of 21 to 30 years (18 cases) and 31 to 40 years (8 cases).
Mode of Injury
Nine patients were involved in vehicular accidents. Eighteen were assaulted with sharp weapons (14 with knife, 1 each with sword and a broken bottle and two with gupti). Three patients gave history of accidental fall. Out of nine vehicular accidents, six were automobile accidents and three patients fell out of a running train while under the influence of alcohol. In our series there was no case due to chemical injury. Deodhar et al  reported two cases of assault with chemicals.
The general condition of the patient on admission proved to be important in the diagnosis, management and prognosis of the patient.
Patients with minor trauma presented with pain, and bleeding. Patients with major trauma presented in a state of shock, manifested by tachycardia, hypotension, perspiration, breathlessness and cold and-clammy extremities (10 cases). Other symptoms were cyanosis and breathlessness (12 cases) haemoptysis (1 case) vomiting (4 cases).
Two patients with flail chest had paradoxical chest wall movements. Four patients with haemopneumothorax had shift of mediastinum to the opposite side, shifting of the apex beat to the opposite side and dull percussion note over the bases and midzones of the lungs, and tympanic note over the apical region. In these cases there were diminished breath sounds on the affected side.
Four patients with thoraco- abdominal injuries, presented with tenderness, guarding and rigidity in the epigastrium, and right and left hypochondria.
Intravenous infusion was started immediately, for the cases in shock. Blood was grouped and cross matched, Nasogastric aspiration was instituted in those who had intra-abdominal injuries. Two patients needed pre-operative blood transfusion, because of the severity of the haemorrhagic shock. Associated injuries were noted. Wounds were covered with sterile dressings.
After the general condition of the patient improved, plain X-rays of the chest and abdomen were taken with the patients in standing position. Haemoglobin and urine examination were done.
None of our patients required angiography or aortography, since our series does not include cardiac trauma or trauma to the major blood vessels.
X-ray chest showed evidence of rib fractures, flail segments, shifting of mediastinum, surgical emphysema and haemopneumothorax. Thoraco-abdominal injuries involving the hollow viscera showed gas under the diaphragm.
(1) Muscle-deeps wounds without any major damage were sutured.
(2) Patients having simple rib fractures were given analgesics. No antibiotics were given in these cases.
(3) Flail segment of the chest wall was firmly strapped. No attempt was made to elevate the flail segment or to immobilise it permanently. These patients had no breathing difficulty. They were given regular physiotherapy for two weeks.
(4) Two patients had tension pneumothorax. They were breathless and cyanosed. They required immediate aspiration of air through second space midclavicular line. Wounds of the chest penetrating pleura were explored.
(5) Haemopneumothorax: A drain was put through seventh intercostal space in the midaxillary line, and connected to underwater seal drainage bottle.
Four patients had thoraco-abdominal injuries. They were explored under general anaesthesia via abdominal incision. In these cases, underwater seal intercostal drainage was instituted preoperatively, to avoid tension pneumothorax, and aid the induction of anaesthesia.
None of our patients required positive pressure respiration.
The incidence of injuries to various organs is indicated in [Table 1].
Three patients had diaphragmatic tears; these were sutured with nonabsorbable material; one was sutured via thoracic approach, and two via abdominal approach. One patient with blunt thoraco-abdominal trauma, was explored by right paramedian incision, he had four liver tears. These were sutured with one zero chromic catgut. We had to do splenectomies in three cases because of splenic tears.
Two patients had stomach perforations of the anterior wall only. These were sutured with non-absorbable material.
Patients with injuries restricted to the parieties were discharged after observation for 48 hours.
Patients with abdominal injuries, were treated with intravenous fluids and nasogastric aspiration till peristalsis returned.
Patients with only thoracic trauma, were given oral fluids on the following day. Endotracheal suction and care of drainage tube taken. Patients were encouraged to cough out. Breathing exercises, analgesics, antibiotics, steam or benzoin inhalations and respiratory physiotherapy, were given. Periodic X-rays chest were taken post-operatively, to confirm expansion of the lung, and to assess the patients' progress. Sutures were usually removed on the 8th day, but kept longer in patients, with wound complication.
Post-operatively, haemoglobin, packed cell volume, periodic X-ray chest, and serum electrolyte estimation were carried out. Arterial blood gas studies were done in four patients having haemopneumothorax. These results are presented in [Table 2].
One patient had chronic discharging sinus over chest wall. Sinogram was done which showed small cavity about 7.5 x 5 cms walled off completely from. the pleural cavity.
(1) Thrombophlebitis-Five patients had thrombophlebitis following venesection, which was treated with thrombophobe ointment and cold compressions. Culture of venesection tip grew Gram negative organisms. (E. Coli 4 cases and Pseudomonas one case).
(2) Two patients had superficial wound infection treated with dressings, local antibiotics and glycerine acriflavin application. No systemic antibiotics were given. They required secondary suturing later on.
(3) One patient had a pleural reaction and thickened pleura. He was advised deep breathing exercises. No antibiotics were given in this case.
(4) Patient with chronic empyema had discharging sinus. Scraping of the cavity was done. Drain was reinstituted, and kept for six days.
In our series of 30 cases, two patients expired. One patient died before treatment could be instituted. Autopsy showed cerebral laceration, crush injury chest with open haemopneumothorax. Second patient had cerebral contusion and liver tears.
Mortality rate was 6.6%.
Chest injuries are divided in two main groups (1) Blunt chest trauma (2) Penetrating injuries.
(1) Blunt Chest trauma
(a) Simple rib fractures-In this type there is a simple fracture of one or more ribs. The chief problem in these cases is pain, which can be treated by oral analgesics and rest. Some patients require potent injectable analgesic for severe pain during the first 24 hours. We did not try intercostal nerve block as advised by Jones et al,  as the effect lasts only for a few hours. Strapping is also inadvisable, as it hampers chest movement and encourages atelectasis.
(b) Rib fractures with chest complications-These may be pleural complications such as haemopneumothorax, pneumothorax and laceration, and chest wall complications such as surgical emphysema (3 cases) and flail chest (2 cases).
(c) Other injuries-One case did not have fracture ribs but the patient had haemoptysis following blunt trauma.
(2) Penetrating Injuries
Surgical emphysema, pneumothorax, haemopneumothorax, lung injury, cardiovascular injury and thoraco-abdominal injuries constitute this group of injury.
(a) Surgical emphysema: In many cases there is no associated pneumothorax 3 Cases of severe and extensive surgical emphysema are associated usually with a tension pneumothorax. The treatment of pneumothorax is all that is needed, following which, the emphysema gets resolved.
(b) Flail Chest: Flail chest should be regarded as a serious complication. The paradoxical movements of the flail and floating segment of chest wall, prevents development of negative intrapleural pressure on the affected side, thereby leading to hypoxia and hypercapnoea. Due to poor venous filling, there is reduction of cardiac output, marked hypotension and tachycardia. Internal fixation and strapping does more harm to the patient's prognosis. Mechanical ventilation appears to be a sound physiological approach to treatment of this injury. 
Pendelluft-The concept of pendulluft implies that during inspiration decrease in lung volume occurs on injured side, as air moves across the carina into the uninjured lung. It is doubtful that pendelluft could occur in situation, where minute volume of air on injured and uninjured sides are equal  There is rise in arterial pCO 2 , and fall in pO 2 .  These patients have low cardiac output and myocardial ischaemia and they may require tracheostomy and assisted respiration.
(c) Pneumothorax: Cases with minimal pneumothorax can be treated by careful observation only, as air gets absorbed spontaneously in about a week.  Cases with tension pneumothorax require immediate needle aspiration. These patients have hypotension due to decreased venous return. A closed tube thoracotomy may be required.
(d) Haemothorax and Haemopneumothorax: The successful management of haemothorax, depends upon evacuation of blood from pleural cavity, and active physio-therapy to achieve pulmonary re-expansion.  Keeler et a1  and Maloney,  have recommended a tube thoracotomy as the treatment of choice in pneumothorax.
Keeler et al  recommend liberal use of exploratory thoracotomy. Ahuja  recommends tube thoracotomy only in cases of tension pneumothorax or a continued haemothorax after 2-3 aspirations.
(e) Injury to the lungs: Lung injuries can be repaired by simple sutures in all cases; lobectomy or segmental resection is seldom required.
(f) Chronic Empyema: Early delayed thoracotomy should be employed if haemothorax is not drained adequately, this prevents need for formal decortication and accomplishes complete lung expansion. 
(g) Injury to the heart and, Great Vessels: Traumatic rupture of the heart or aorta has a grave but not necessarily a hopeless prognosis, if it is adequately managed. Death may be instantaneous, and only 10-20% of the patients reach the hospital alive. Nevertheless, those that do, may survive for many hours or several days, although the aorta may be severely damaged. 
(h) Thoraco-abdominal injuries: It is very important to look for associated abdominal injuries since 5 of our cases had major abdominal trauma. Injury to the spleen and liver is more common than that to hollow abdominal viscera.
Abdomen may be explored separately or via exploratory thoracotomy and incising the diaphragm. There is always, a danger of contaminating the pleural space by stomach secretions or intestinal secretions in - the later approach. Rajdeo and Deodhar  prefer to perform an exploratory laparotomy for the management of intra-abdominal injury, with intercostal drainage' and observation of chest injury. This is probably because of greater familiarity of the general surgeon, with the abdominal approach than with the thoracic.
In our series, the two deaths were because of associated injuries. Hence it is very important to look for associated injuries. Our mortality rate is 6.6%
Nair et a1  in a study of 300 cases recorded 16 deaths, giving 5.3% mortality.
Beall et al  recorded 11.5% mortality in blunt trauma and 7.4% in penetrating trauma. Mortality rates are compared in [Table 3].
The commonest causes of death in the cases of chest injuries, are tension pneumothorax, cardiac injuries, .haemopneumothorax and complications following chest injuries, like empyema and bronchopneumonia. 
Complete recovery in cases of severe chest injuries, cannot be achieved without proper physiotherapy. Early ambulation, active coughing and deep breathing exercises and benzoin inhalation will prevent the complications like bronchopneumonia, empyema, upper respiratory tract infection and deep venous thrombosis. Steam humidifier can be used to liquify thick secretions. Mucolytic enzymes can be used in humidifier. Infra red light can be used to prevent wound infection.
It reduces airway resistance and dead space. thus improves ventilatory efficiency. It also prevents atelectasis and pneumonitis from retained tracheobronchial secretions.
Intermittent Positive Pressure Respiration (I.P.P.R.)
This may be required in patients having major flail segment, with parodoxical respiration, as it reduces dead space and improves ventilation. Respiratory effort is also minimised. Before putting patient on I.P.P.R., one must rule out tension pneumothorax. In such cases intercostal drain is instituted before hand. Upper respiratory tract infection bronchopneumonia and electrolyte imbalance are the major complications of I.P.P.R. and its management requires trained personnel.
Chest injuries are fairly common, and form a fair number of admissions to a surgical ward. Detailed examination at the time of admission is necessary, to assess the presence of major complications, like haemothorax, haemopneumothorax, lung tear and penetrating thoraco-abdominal injuries. Institution of intrapleural drainage, and restoration of negative intrapleural pressure, followed by active respiratory physiotherapy, constitute an important part of the treatment. Abdominal injuries require management on their merit.
Thanks are due to the Dean, K.E.M. Hospital, Parel, Bombay, for permission to use the hospital records. Thanks are also due to members of the resident and nursing staff for valuable co-operation. We are thankful to the physiotherapists who were actively concerned with the management.
[Table 1], [Table 2], [Table 3]