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 ::  Material And Methods
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ARTICLE
Year : 1979  |  Volume : 25  |  Issue : 3  |  Page : 134-139

Chest injuries in civilian practice (A study of 166 cases)


1 Department of Cardiovascular Surgery, L.T.M.M. College and L. T.M.G. Hospital, Sion, Bombay-400 022, India
2 Department of General Surgery, L.T.M.M. College and L. T.M.G. Hospital, Sion, Bombay-400 022, India

Correspondence Address:
N V Mandke
Department of Cardiovascular Surgery, L.T.M.M. College and L. T.M.G. Hospital, Sion, Bombay-400 022
India
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Source of Support: None, Conflict of Interest: None


PMID: 529165

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 :: Abstract 

Chest injuries constitute a large number of patients admitted in our Intensive Trauma Care Unit. The maximum incidence is in the age group of 20-40 years. Contusions, fracture ribs, pneumo­haemothorax constitute major thoracic injuries. Visceral injuries were always kept in mind while treating these patients with critical condition. Most of the patients could be treated with only active conservativemanagement with proper use of respirators in selected patients. Surgical intervention was required in the patients mostly with visceral injuries.
The mortality rate in pure chest injuries is very low. The as­sociated head injuries and abdominal injuries increased the overall mortality rate.



How to cite this article:
Mandke N V, Padmanabhan C, Shah A M, Nadkarni S V. Chest injuries in civilian practice (A study of 166 cases). J Postgrad Med 1979;25:134-9

How to cite this URL:
Mandke N V, Padmanabhan C, Shah A M, Nadkarni S V. Chest injuries in civilian practice (A study of 166 cases). J Postgrad Med [serial online] 1979 [cited 2019 Dec 12];25:134-9. Available from: http://www.jpgmonline.com/text.asp?1979/25/3/134/42129



 :: Introduction Top


Thoracic injuries may be due to vari­ous causes and may result in injury to any one or several intrathoracic organs. Associated abdominal and head injuries are also found along with the thoracic in­juries.

Patients with severe chest injuries are frequently in critical condition and in need of urgent care, but only about 10 per cent require major thoracotomy, Montgomery [9] in 1947. reported only one death in 100 patients treated for chest in­juries without operation. The immediate needs are resuscitation from the shock of the injury and the associated blood loss and the restoration of cardiorespiratory dynamics. The impairment in cardiorespiratory dynamics may either be due to sucking wounds or loss of dia­phragmatic action or interference with lung expansion by fluid and air in the pleural cavity or damage in the lungs or restricted motion of the chest wall due to pain.

Any obstruction to the air-way needs to be relieved promptly. [4] The importance of the tracheostomy and positive pressure breathing has been emphasized by Carter and Guiseffi, [4] and by Motley et at. [10] In 1946, Burke and Jacobs [3] found haemo­thorax to be the commonest complication of penetrating wounds of the chest. Con­tinued haemorrhage should be suspected if there is only partial or no response to blood transfusion, if there is a rapid ac­cumulation of blood within the pleural cavity after aspiration, or if blood con­tinues to escape from the wound [3],[8],[12] Continued bleeding is the indication for immediate thoracotomy, and the most likely cause may be due to the injury to the heart, great vessels or arch vessels. [3],[8],[9],[12]

The present report mainly outlines the crucial management of various types of chest injuries we came across in one year's time.


 :: Material And Methods Top


One hundred and sixty six patients were admitted in L.T.M.G. Hospital, Sion, for thoracic injuries in one year's period. All these patients were admitted in emer­gency ward and were thoroughly examin­ed. Initial clinical examination was carried out, to find out the extent and severity of injury and any associated in­jury like intra-abdominal catastrophy, head injury or any fracture.

Investigations were basically carried out from the point of arriving at the de­finite diagnosis and extent of injury. Portable chest X-Ray, complete haemo­gram and blood grouping were done in all the cases. Associated pathologies re­quired additional investigations like skull X-Rays, abdominal X-Rays, skiagrams of fractured bones, etc.

Patients with severe chest injuries with flail segments were put on respirator with endotracheal tubes. [4],[7] Most of the patients were given intravenous fluid therapy via basilic central venous cut down. Blood pressure. pulse rate, CVP monitoring were done in all the cases. Parenteral antibiotic therapy was im­mediately instituted in all the patients. Depending on the clinical and radiological findings, patients were subjected to either conservative or surgical management.


 :: Results Top


Results mainly depended upon com­plicating factors along with the severity of the injury as well as the time duration between the occurrence of injury and the starting of treatment.

In our series, the age of the patients ranged from 5 years up to 94 years with the maximum incidence between 20 to 40 years of age. Out of 166 patients, 136 were males and only 30 were females.

Patients came with variety of causes of injury, the commonest being railway ac­cidents. Out of 166 patients, 61 patients came with railway accidents, 39 had stab wounds, 35 were inflicted in automobile accidents, 16 had some sort of assault and remaining were due to blast injuries, gun­shot and fall from the height.

Pathology (Spectrum of injuries)

The most common chest injuries were rib fractures, haemothorax, pneumo­thorax and haemopneumothorax. Out of 166 cases, 99 had rib fractures, out of which 43 had more than 3 ribs fractured, and 33 cases were either associated with haemothorax or pneumothorax or both. We had 7 cases of bilateral chest injuries, out of which 5 were associated with bila­teral haemo-pneumothorax.

Out of 39 stab injuries of the chest, 17 were muscle deep (extrathoracic) while 22 were pleura-deep (intra-thoracic). Eight cases had pulmonary contusion with intrapulmonary haematoma which was diagnosed by chest roentgenogram. Six patients from this group showed evidence of `Traumatic Wet Lung Syn­drome'. Four cases had Cardiac injury.

[Table 1] presents the analysis of the spectrum of chest injuries.

Management

Management of thoracic injuries was broadly divided in two parts:

1. Active conservative management.

2. Surgical management.

1. Active conservative management

A careful general examination suppli­mented by a skiagram of chest gave an idea of the nature and extent of chest in­juries. [1] Endotracheal intubation was re­quired mainly in cases with multiple rile fractures along with flail segment, Tracheostomy and IPPR was found necessary to maintain adequate oxygena­tion in these patients. [4],[7],[10] Frequent monitoring of heart rate, blood pressure, haemotocrit values and CVP were carried out till patient got stabilized. Ringer lactate solution, haemaccel and glucose saline were infused immediately on ad­mission in severely hypovolaemic patients till blood was available for trans­fusion. Blood transfusions were given to maintain the blood volume and the ad­equacy was judged by haemoglobin, PCV estimation and CVP readings. [8],[12]

Further management was decided up­on by the type and extent of the injury. Fracture ribs were supported by strap­ping. [8] Haemopneumothorax was drained by intercostal drains [3],[8],[9],[12] and flail chests were stabilized by intermittent positive pressure respiration (IPPR) with the help of respirator [7],[10] (See [Figure 1],[Figure 2] and [Figure 3] on page 136A).

Such critically ill patients were moni­tored with blood gas studies. [7],[8],[10],[12] Tracheostomy was performed in 16 out of 27 cases which required endotracheal intubation on admission and out of which 14 patients required IPPR for more than 5 days. [4],[10] Six patients in this group developed `Traumatic Wet Lung Syn­drome' and were treated with IPPR, tra­cheobronchial toilet and anticoagulant therapy for more than 7 to 10 days. [2],[4],[8],[10],[12] They were assessed with chest skiagram and blood gas studies every day. [8]

2. Surgical management

Exploratory thoracotomy was perform­ed in 16 cases out of 166 patients (9.6%) and thoraco-abdominal exploration in 6 cases (3.6%). Only 11 patients with lung tears were treated by exploration and lung tear was sutured. Traumatic rupture of the diaphragm was encounter­ed in 6 cases out of which 5 were diagnos­ed preoperatively and treated by emer­gency thoracotomy. [1],[9],[13] See [Figure 4] on page 136B). Of these 5, three had asso­ciated abdominal injuries and required thoraco-abdominal explorations. [1],[8],[9],[13] One out of 6 patients who had thoraco­abdominal exploration was diagnosed as a case of diaphragmatic hernia two months later by barium enema (18 year old male with the history of stab wound), and planned diaphragmatic re­pair was performed. [1],[13] All these repairs could be achieved by direct closure of the diaphragmatic defects.

We had one case of esophageal tear along with lung tear. Patient was in a very critical stage and died within one hour of admission. The diagnosis of oesophageal tear was confirmed on autopsy.

In this series, 4 patients had cardiac injuries , [3],[8],[9],[11] two, stab wounds; one, nail injury and one had penetrating in­jury with a sharp fork See [Figure 5],[Figure 6] and[Figure 7] on page 136B). All were operated, the two with the stab died on operation table due to hypovolaemia and ventricular fibrillation, and the other two recovered completely, with no residual damage.

Mortality

In this series, 41 cases out of 166 patients died (overall mortality of 24.6%). Of 94 patients with isolated thoracic injuries only 5 patients died. [Table 2] summarises the causes of death in these 5 patients. Associated head in­jury, abdominal trauma and orthopaedic injury added to the mortality of these patients. [Table 3].


 :: Discussion Top


We have studied 166 cases of chest injuries over a period of one year at our institution. The commonest cause of chest injuries with us was railway accidents. Out of 166 cases 99 cases has rib fractures and out of these 32 cases; had haemopneumothorax. Burke and Jacobs [3] in 1946 found haemothorax to be the most common complication of chest wounds.

Out of 166 chest injuries, only 16 case: required exploratory thoracotomies ant 6 cases underwent thoracoabdominal explorations. According to our experience active conservative management', if properly carried out is usually adequate it most of the cases. [2],[5]

Howell et al, [7] in 1963, advocated surgical fixation of fractured ribs with steel wires as a support to the unstable chest wall segments, either alone or along with IPPR. We have not tried surgical fixation of the fractured ribs and we have found stabilization of he flail segment with IPPR quite satisfactory [Figure 1] and [Figure 2]. It only requires meticulous care of endotracheal tube or tracheostomy tube with careful monitoring of blood gas studies.

Traumatic diaphragmatic defects do no tend to heal spontaneously. Apparently that is related to the pleuro-peritoneal pressure gradient, across the diaphragm normally present. This pleuroperitoneal gradient can be in excess of 100 Cm H­ 2 O on maximum inspiratory effort. That is how the abdominal contents get pushes upwards especially on the left unprotected hemidiaphragm, and produce herniation of the abdominal viscera into the chest. The massiveness depends upon the force of injury with the raised intra abdominal pressure and the size of rent into the diaphragm. Most of the times, the rent in the diaphragm could be ap­proximated without any problems. [13] In our 6 patients, we had no difficulty in suturing the traumatic diaphragmatic defects at the time of surgery.

Of 94 isolated thoracic- injuries, only 5 patients died [Table 2] giving us the mortality rate which is considerably lower than in the patients with associated abdominal and head injuries, Howell [7] and Hughes [8] in 1963 separately reported nearly the same incidence of mortality with associated pathologies and isolated chest injuries.

We have encountered post-traumatic wet lung syndrome only in 6 cases and 4 of them recovered completely. The re­covery period was quite stormy and pro­longed. [2] Hill et ale [6] in 1972 reported the use of membrane oxygenator for long term traumatic wet lung syndrome.

We feel, that the correct diagnosis and very prompt management will help to re­duce the mortality in chest injuries. [1] The role of IPPR is undoubtedly important in stabilizing the cases with critical levels of ventilation-perfusion abnormalities. [2],[7],[10]


 :: Acknowledgements Top


We are thankful to the Dean, L.T.M.M. College and L.T.M.G. Hospital for allow­ing us to publish the hospital data.

 
 :: References Top

1.Blair, E., Topuzlu, C. and Davis, J. H.: Delayed or missed diagnosis in blunt chest trauma. J. Trauma, 11: 129-133, 1971.  Back to cited text no. 1    
2.Burford, T. H. and Burbank, B.: Trauma­tic wet lung: Observations on certain physiologic fundamentals . of thoracic trauma. J.. Thoracic Surg., 14: 415-424, 1945.  Back to cited text no. 2    
3.Burke, J. and Jacobs, T. T.: Penetrating wounds of the chest. Ann. Surg., 123: 363-376, 1946.  Back to cited text no. 3    
4.Carter, B. N. and Giuseffi, J.: Tracheo­stomy-a useful procedure in thoracic surgery with particular reference to its employment in crushing injuries of thorax. J. Thoracic Surg., 21: 495-505, 1951.  Back to cited text no. 4    
5.Errion, A. R., Houk, V. N. and Kettering, D. L.: Pulmonary hermatoma due to blunt non-penetrating thoracic trauma. Amer. Rev. Resp. Dis., 88. 384-388, 1963.  Back to cited text no. 5    
6.Hill, J. D., DeLeval, M. R., Fallat, R. J., Bramson, M. L., Eberhart, R. C., Schulte, H. D. Osborn, J. J., Barber, R. and Gerbode, F.: Acute respiratory insuffici­ ency: Treatment with prolonged extra­corporeal oxygenator_ J. Thoracic & Car­diovasc. Surg., 64: 551-561, 1972.  Back to cited text no. 6    
7.Howell, J. F., Crawford, E. S. and Jon­dan, G. L.: The flail chest: an analysis of 100 patients. Amer. J. Surg. 106: 629-635, 1963.  Back to cited text no. 7    
8.Hughes, R. K.: Thoracic trauma-A col­lective review. Ann. Thoracic. Surg., 1; 778-804, 1965.  Back to cited text no. 8    
9.Montgomery, II., Halbersleben, D. and Carr, F. B.: Puncture wounds of the chest. J. Thoracic Surg., 16: 407-415, 1947.  Back to cited text no. 9    
10.Motley, H, L., Cournac, A., Werko, L., Dresdale, D. T., Hemmilstein, A. and Richards, D. W.: Intermittent positive pressure breathing. J. Amer. Med. Assoc., 137: 370-382, 1948.  Back to cited text no. 10    
11.Noon, G. P., Boulafedis, D. and Beall, A. C. Jr.: Rupture of the heart secondary to blunt trauma. J. Trauma, 11: 122-125, 1971.  Back to cited text no. 11    
12.Simson, P. C., Burbank, B., Brewer, L. A. III and Burford, T. H.: Immediate care of the wounded thorax. J. Amer. Med. Assoc., 129: 606-610, 1945.  Back to cited text no. 12    
13.Wise, L., Hwang, Y. H. and Anderson, C.: Traumatic injuries to the diaphragm. J. Trauma, 13: 946-951, 1973.  Back to cited text no. 13    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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