Journal of Postgraduate Medicine
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ARTICLE
 
 
Year : 1979  |  Volume : 25  |  Issue : 1  |  Page : 33-40  

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

Correspondence Address:
S D Deodhar
Department of Surgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay 400 012
India

Abstract

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



How to cite this article:
Deodhar S D, Pallod G B. Injuries of the chest*.J Postgrad Med 1979;25:33-40


How to cite this URL:
Deodhar S D, Pallod G B. Injuries of the chest*. J Postgrad Med [serial online] 1979 [cited 2019 Sep 22 ];25:33-40
Available from: http://www.jpgmonline.com/text.asp?1979/25/1/33/42103


Full Text

 Introduction



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.

 Material And Methods



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.

 Clinical Data



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 [5] reported two cases of assault with chemi­cals.

Symptomatology

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).

Signs

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.

Pre-operative Management

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.

Investigations

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.

Operative Management

(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.

Post-operative Management

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.

Post-operative Complications

(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.

Mortality

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%.

 Discussion



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, [8] 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. [11]

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 [9] There is rise in arterial pCO 2 , and fall in pO 2 . [11] 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. [12] 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. [2] Keeler et a1 [9] and Maloney, [10] have recommended a tube thoracotomy as the treatment of choice in pneumothorax.

Keeler et al [9] recommend liberal use of exploratory thoracotomy. Ahuja [1] 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. [4]

(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. [6]

(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 [13] 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.

Mortality

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 [12] in a study of 300 cases re­corded 16 deaths, giving 5.3% mortality.

Beall et al [2] 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. [13]

Physiotherapy

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.

Tracheostomy

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.

 Conclusions



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.

 Acknowledgements



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.

References

1Ahuja, A. M.: Management of penetrat­ing war wounds of the chest, Indian J. Surg., 28: 667-674, 1966.
2Beall, A. C. Jr., Crawford, H. W. and DeBakey, M. E.: Considerations in the management of acute traumatic haemo­thorax, J. Thoracic and Cardiovas. Surg.,52: 351-360, 1966.
3Cosgriff, J. H. and Hale, H. W. Jr.: Is simple rib fracture a simple injury? Amer. J. Surg., 69: 569-574, 1959.
4Culiner, M. M., Roe, B. B. and Grimes, 0. F.: The early elective surgical approach to the treatment of traumatic haemotho­rax, J. Thoracic and Cardiovas. Surg., 38: 780-797, 1959.
5Deodhar, S. D., Majumdar, H. P. and Agrawal, J. B.: Patterns of assault, Indian J. Med.. Sci., 30: 95-97, 1976.
6Deodhar, S. D., Bapat, R. D. and Iyengar, R. G.: Rupture of thoracic aorta follow­ing closed thoracic injury-a case report, J. Postgrad. Med., 16: 163-166, 1970.
7Harrison, W. H. Jr., Gary, A, R., Couves, C. M. and Howard, J. M.: Severe non­penetrating injuries of the chest, Amer. J. Surg., 100: 715-722, 1960.
8Jones, R. J., Samson, P. C. and Dugan, D. J.: Current management of civilian thoracic trauma, Amer. J. Surg., 114: 289-296, 1967.
9Keeler, J. W., Meckstroch, C. V., Son­cenbacher, L. and Pace, W. G.: Thoracic injuries due to blunt trauma, J. Trauma, 7: 541-552, 1969.
10Maloney, J. V., Schmutzer, K. J. and Raschke, E. V.: Paradoxical respiration and pendelluft, J. Thoracic and Cardio­vas. Surg., 41: 291-298, 1961.
11Maloney, J. V. and Mcdonald, L.: Treat­ment of blunt trauma to the thorax, Amer. J. Surg., 105: 484-489, 1963.
12Nair, S. K., Sharma, M. H. and Saigal, V. K.: An experience with 300 cases of acute chest injuries, Indian J. Surg., 33: 376-381, 1971.
13Rajdeo, H. P. and Deodhar, S. D.: Stab wound of the abdomen-A study of 75 cases, Indian J. Med. Sci., 29: 54-59, 1975

 
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