Chest injuries in civilian practice (A study of 166 cases)NV Mandke1, C Padmanabhan1, AM Shah2, SV Nadkarni2
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: Source of Support: None, Conflict of Interest: None PMID: 529165
Source of Support: None, Conflict of Interest: None
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.
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  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.  The importance of the tracheostomy and positive pressure breathing has been emphasized by Carter and Guiseffi,  and by Motley et at.  In 1946, Burke and Jacobs  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 ,, 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. ,,,
The present report mainly outlines the crucial management of various types of chest injuries we came across in one year's time.
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. , 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 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 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.  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. ,, 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. ,
Further management was decided upon by the type and extent of the injury. Fracture ribs were supported by strapping.  Haemopneumothorax was drained by intercostal drains ,,, and flail chests were stabilized by intermittent positive pressure respiration (IPPR) with the help of respirator , (See [Figure 1],[Figure 2] and [Figure 3] on page 136A).
Such critically ill patients were monitored with blood gas studies. ,,, 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. , 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. ,,,, They were assessed with chest skiagram and blood gas studies every day. 
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. ,, See [Figure 4] on page 136B). Of these 5, three had associated abdominal injuries and required thoraco-abdominal explorations. ,,, 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. , 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 , ,,, 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.
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].
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  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. ,
Howell et al,  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.  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  and Hughes  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.  Hill et ale  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.  The role of IPPR is undoubtedly important in stabilizing the cases with critical levels of ventilation-perfusion abnormalities. ,,
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.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]