Pakistan Journal of Medical Sciences

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ORIGINAL ARTICLE

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Volume 25

April - June 2009 (Part-I)

Number  2


 

Abstract
PDF of this Article

Chest Trauma Management: Good outcomes
possible in a general surgical unit

Muhammad Laiq uz Zaman Khan1, Jahanzaib Haider2,
Shams Nadeem Alam3, Masood Jawaid4, Khalid Ahsan Malik5

ABSTRACT

Objective: To determine the predominant pattern of injuries following chest trauma and assess the adequacy of the management strategies employed in a general surgical unit of a trauma care hospital.

Methodology: This Case Series study with prospective data collection was conducted in Surgical Unit-II & Unit-VI of Civil Hospital Karachi, from September 2007 to February 2009. One hundred and three consecutive patients with thoracic trauma presenting in emergency department were evaluated. Patients above 12 years of age, who presented with chest trauma either alone or associated with multiple trauma were included.

Results: A total of 103 patients were studied for various chest injuries during eighteen months period. As a whole 58% of patients had blunt chest injury as compared to 42% who had penetrating injuries. Thirty patients (29%) had chest wall injuries (rib fracture, mild lung contusion) without haemothorax or pneumothorax, who were managed conservatively. Chest intubation was required in 64 patients (62%) having hemothorax / pneumothorax. Thoracotomy was required in nine patients (9%), in which only two were emergency thoracotomy and seven were elective. Over all mortality rate was 8%.

Conclusion: Penetrating injury of chest is rising with time due to gunshot injuries although blunt trauma is still more common. Majority of chest trauma patients can be managed in a general surgical unit satisfactorily and few patients need major operative management.

KEY WORD: Chest trauma, Tube thoracostomy, Pneumothorax, Hemothorax, Blunt trauma, Penetrating trauma.

Pak J Med Sci    April - June 2009    Vol. 25 No. 2    217-221

How to cite this article:

Khan MLZ, Haider J, Alam SN, Jawaid M, Malik KA. Chest Trauma Management:Good outcomes possible in a general surgical unit. Pak J Med Sci 2009;25(2):217-221.


1. Dr. Muhammad Laiq uz Zaman Khan FCPS
Senior Registrar
2. Dr. Jahanzaib Haider FCPS
Senior Registrar
3. Dr. Shams Nadeem Alam FRCS
Associate Professor
4. Dr. Masood Jawaid FCPS
Medical Officer
5. Prof. Khalid Ahsan Malik MS
Professor of Surgery
1-5: Surgical Unit VI,
Civil Hospital Karachi &
Dow University of Health Sciences,
Karachi - Pakistan.

Correspondence

Dr. Muhammad Laiq uz Zaman Khan, FCPS
Senior Registrar
Surgical Unit VI,
Civil Hospital &
Dow Medical College.
Karachi. Pakistan.
Email: drlaiq@yahoo.co.uk

* Received for Publication: April 5, 2009
* Revision Received: April 14, 2009
* 2nd Revision Received: May 1, 2009
* Final Revision Accepted: May 5, 2009


INTRODUCTION

Trauma is the leading cause of morbidity and mortality, especially during the first four decades of life.1 No published national data base of trauma is available. Accidents and armed violence is a cause of increasing penetrating injuries of chest. According to United States National Trauma Data Bank, admissions due to trauma have steadily grown in the last decade,2,3 which is 12 per million population per day and 20 to 25% of deaths occurring due to trauma in the United States are due to thoracic injuries.4 Many patients with chest trauma die after reaching the hospital.5 Many of these deaths can be prevented by prompt diagnosis and correct management.6 In this anatomical region, operative dexterity and knowledge of a general surgeon can not be compared to that of their cardiothoracic colleagues.7 In spite of the high mortality rates, about 80-90% of the patients with life-threatening thoracic injuries can be managed by a simple intervention like drainage of the pleural space by tube thoracostomy.5,8,9 The critical condition of these patients can make their surgical management challenging for the general surgeon.7

Among the causes of thoracic trauma road traffic accidents, fire arm injuries and stab wounds take the major share.10 Pre hospital deaths resulting from thoracic injuries are due to great vessels rupture and exsanguinations, cardiac tamponade,11 tension pneumothorax and bilateral flail chest with deep refractory hypoxia. All patients who reach hospital alive should survive by appropriate management.12

The objective of the study was to determine the predominant pattern of injuries following blunt and penetrating chest trauma and assess the adequacy of the management strategies based on Primary Trauma Care (PTC) guidelines13 employed for chest trauma in a general surgical unit of a trauma care hospital.

METHODOLOGY

This case series was conducted in Surgical Unit-II and VI of Civil Hospital Karachi, from September 2007 to February 2009. One hundred and three consecutive patients with thoracic trauma presenting in emergency department were evaluated. Patients above 12 years of age, who presented with chest trauma either alone or associated with multiple trauma were included. All patients were managed according to PTC guidelines. Life threatening injuries were managed as evident from clinical assessment in the emergency room; for example, immediate tube thoracostomy of a tension pneumothorax patient was done. Secondary survey was performed after patient was stabilized. Investigations included blood complete picture, X-ray chest and abdominal X-ray, ultrasound and blood grouping, were also done where indicated.

The management ranged from tube thoracostomy to thoracotomy and ventilator support. ICU care was also provided where indicated. Patients having minor chest wall injuries, rib fractures without haemo / pneumothorax and mild lung contusion were treated with conservative treatment only. Patient having blood and air in pleura were treated with chest intubation. Initial management of life threatening thoracic injuries was carried out according to type of trauma and nature of injury.

RESULTS

A total of 103 patients were studied for various chest injuries during eighteen months period. The age of the patients ranged from 12 to 70 years with a mean age of 36 years. Ninety five patients were males and only eight were females. Mode of injury is mentiond in Table-I.

As a whole 58% of patients had blunt chest injury as compared to 42% who had penetrating injuries. Thirty patients (29%) had chest wall injury (rib fracture, mild lung contusion) without hemothorax or pneumothorax and they were managed conservatively. Chest intubation was required in 64 patients (62%) having hemothorax / pneumothorax which included 34 patients who had penetrating injuries and 30 patients who had blunt chest trauma (Table-II).

Thoracotomy was required in nine patients, in which only two were emergency thoracotomy and seven were elective. All thoracotomies were performed in penetrating injuries. Indication of emergency thoracotomy was initial drainage of blood >1500ml on chest intubation and internal mammary artery bleeding was found on surgery. Elective thoracotomies were performed by thoracic surgery department of Jinnah Postgraduate Medical Center, Karachi, where patients were referred after emergency management of chest trauma, in which five had bronchopleural fistula, two patients developed empyema as a complication of chest intubation and required decortication (Table-III).

Twelve patients had associated injuries to abdomen, head and neck, limbs and eight had multiple injuries involving thorax with more than two body systems. Five patients had diaphragmatic rupture, which were repaired during laparotomy. Those patients who had neurosurgery problem were admitted in neurosurgery ward, but were followed up there. Two patients with flail chest did well with chest intubation, oxygen and pain control, while one patient required ventilator support.

Fifteen patients developed post operative complications of chest intubation, in which two had empyema, eight had pneumonia and five had wound infection. In multiple trauma four patients developed Acute Respiratory Distress Syndrome (ARDS) and four patients developed septicemia. Eleven patients had respiratory tract infection during conservative treatment, in which three had lung contusion. Over all mortality was eight (8%), in which five had multiple trauma and two had associated neurosurgical trauma and one with flail chest on ventilator support.

DISCUSSION

Most general surgeons feel competent to be involved in the management of multisystem injured patients and undertake abdominal surgery for trauma. However, there is reduced confidence in the management of retroperitoneal, cardiothoracic injuries and vascular injuries.14 The report Better Care for the Severely Injured states that an experienced general surgeon trained in the techniques required to perform life-saving emergency surgery is vital in the management of major trauma.15 A study conducted in UK showed that most general surgeons should retain the ability to manage trauma. They consider that the best service for severely injured patients would be to manage their injuries at a hospital with a specialist trauma service either through direct referral from the roadside or transfer from an acute receiving hospital after the initial resuscitation and stabilization.14

At Civil Hospital Karachi, where thoracic surgery expertise is not available, it is the general surgical team who is responsible to provide immediate surgical management to chest trauma patients. In spite of the high mortality rates, surgical intervention for cardiothoracic injuries is required in less than 10% of blunt thoracic5,16 and 15-30% of penetrating thoracic injuries.16 Many western studies also suggest that observation or chest tube placement, adequate volume replacement, occasional respiratory support and serial chest X-rays are the only treatment required in 80-85% of the patients.17-20 In this study same simple principles of chest trauma management alongwith PTC guidelines resulted in successful management of 85% of the cases. Adding ventilator support, this success rate of management increased to 92% without a major thoracic operative procedure like thoracotomy, which is not different from the rate shown by Farooq1 in their study and Hanif9 shows this rate up to 85%.

The mean age of patients in this study was 36 years with the range of 12-70 years, while Farooq1 shows 37 years and Hanif9 30 years in their studies. Ninety four percent of patients were males, which shows that chest trauma is common in second to fifth decade of age and in males. In the current study blunt trauma was common (58%) than penetrating trauma (42%) while Farooq1 shows the prevalence of blunt trauma and penetrating injuries as 44% and 56% while Hanif9 shows these figures as 65% and 35% respectively. It supports the observation that incidence of penetrating trauma is rising with time because of gun shot injuries.

Formal chest operations other than minor procedures are required by only 12 to 15 per cent of patients with thoracic trauma.21 For those patients requiring thoracotomy, the operation may be required acutely or on a delayed basis. The unstable patient may necessitate thoracotomy at the emergency room to drain cardiac tamponade, provide cardiac massage and control bleeding.22 In this study two emergency thoracotomies were done because initial blood drainage was >1500ml on chest intubation and found bleeding vessel on thoracotomy, while rest of thoracotomies were electively performed by thoracic surgeon for empyema and broncholpleural fistulas. Farooq at el1 also reported that 80% of thoracotomies in penetrating injury were peformed because of bleeding vessels. Overall thoracotomy rate was 9% which is same as Hanif et al9 has mentioned and 8% reported by Farooq et al1 in their studies. All nine thoracotomies were done in penetrating chest injury patients, which was 21% of penetrating chest trauma, in which only two were emergency thoracotomies which is about 22% of total thoracotomies of trauma patients. Thoracotomies in penetrating injuries in other studies are reported 25% by Rubikas.22 In this study no thoracotomy was required in blunt trauma during study period, while Rubikas23 has reported it in less than 3%. Stahel et al5 have reported this in less than 10% in their study. It shows thoracotomy rate is more in penetrating injury than blunt trauma. Complete pneumonactomies are indicated only in few cases under going emergency thoracotomy after penetrating lung trauma,24,25 but none was seen in this study.

Thirty (29%) patients had no hemo/pneumothorax and they were managed conservatively without any surgical intervention by sufficient analgesia, chest physiotherapy and clearance of bronchial secretions and antibiotics to prevent respiratory tract infection. Two patients (2%) developed empyema as post operative complications of chest intubation and required decortications. This is in comparison to 3% by Helling and associates.26

Rib fracture were found in 44% of cases in the study by Farooq et al1 and 76% in Hanif et al9 while in our study the frequency of rib fracture was 85% as compared to 44% and 76% reported by other local authors, while Flail chest was found in 3% in comparison to 20% shown by Farooq1 and 6.6% by Hanif.9 Ventilatory support was required by 9% of patients who had flail chest or multiple trauma. Western studies show a high morbidity due to ventilator support from conditions like barotraumas and volutrauma ending up in ARDS.25,27 ARDS is a main contributor to a mortality rate of 30 to 60% seen in ventilated patients.1

Overall mortality rate was 8% in which five patients had multiple trauma, two had associated neurosurgical trauma and one with flail chest, each of them was put on ventilator support. Three of them had lung contusion and developed ARDS and four had septicemia and one had multiple organ failure due to SIRS. Our mortality rate is comparable to other studies as Farooq et al1 and Hanif et al9 who have reported mortality rate of 7%.

CONCLUSION

Penetrating injury of chest is rising with time due to gunshot injuries although blunt trauma is still more. We feel that majority of chest trauma patients can be satisfactorily managed in a general surgical unit and only a few patients need major operative management like thoracotomy.

REFERENCES

1. Farooq U, Raza W, Zia N, Hanif M, Khan MM. Classification and management of chest trauma. J Coll Physicians Surg Pak 2006;16(2):101-3.

2. American College of Surgeons. National trauma data bank. Chicago: Ann Surg 2004;240:96-104.

3. Choi KC, Peek-Asa C, Lovell M, Tomer JC, Zwerling C, Kaeley GP. Complications after therapeutic trauma laparotomy. J Am Coll Surg 2005;201:546-53.

4. Locicerco J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-6.

5. Stahel PF, Schneider P, Buhr HJ, Kruschewski M. Emergency management of thoracic trauma. Orthopade 2005;34(9):865-79.

6. Kent WJ. Thoracic trauma. Surg Clin N Am 1980;60:957-81.

7. Degiannis E, Zinn RJ. Pitfalls in penetrating thoracic trauma (lessons we learned the hard way…). Ulus Trauma Acil Cerrahi Derg 2008;14(4):261-7.

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10. Cuschieri, GR. Giles AR. Moosa; Essential Surgical Practice 3rd Ed. Oxford: Butterworth-Heinemann Ltd; 1995;521-30.

11. May AK, Patterson MA, Rue LW. Combined blunt cardiac and pericardial rupture; review of the literature and report of new diagnostic algorithm. Am Surg 1999;65(6):568-74.

12. Sabiston DC. Trauma, Management of acute injuries; Text book of Surgery, 17th Ed; Saunders. 2004;258-95.

13. Primary Trauma Care Foundation [home page on the Internet]. Cited 2009 March 1. available from URL: http://www.primarytraumacare.org

14. Brooks A, Butcher W, Walsh M, Lambert A, Browne J, Ryan J. The experience and training of British general surgeons in trauma surgery for the abdomen, thorax and major vessels. Ann R Coll Surg Engl 2002;84:409-13.

15. Anonymous. Better Care for the Severely Injured. Joint report of The Royal College of Surgeons of England and the British Orthopaedic Association; London: 2000.

16. Anonymous. American College of Surgeons. Advanced Trauma Life Support (ATLS) student manual. 6th ed. Chicago, IL: American College of Surgeons, 1997.

17. Bastos R, Baisden CE, Harker L, Calhoon JH. Penetrating thoracic trauma. Semin Thorac Cardiovasc Surg 2008;20(1):19-25.

18. Richordson JD. Indications for thoracotomy in thoracic trauma. Curr Surg 1985;42:361-3.

19. Washinton B, Wilson RF, Steiger Z, Basset JS. Emergency thoracotomy: a four year review. Ann thorac Surg 1985;40:188-91.

20. Robison PD, Harman PK, Tinkle JK, Grover FL. Management of penetrating lung injuries in civilian practice. J Thorac Cardiovasc Surg 1988;95:184-90.

21. Mattox KL. Indications for thoracotomy: deciding to operate. Surg Clin North Am 1989; 69(1):47-58.

22. Bastos R, Baisden CE, Harker L, Calhoon JH. Penetrating thoracic trauma. Semin Thorac Cardiovasc Surg 2008;20(1):19-25.

23. Rubikas R. Emergency thoracotomy. Medicina (Kaunas) 2003;39(2):158-67.

24. Jantz Ma, Pierson DJ. Pneumothorax and barotraumas. Clin Chest Med 1994;15:75-6.

25. Lopez Roderiguez A, Lopez Sanchez L, Julia J. Pneumoperitoneum associated with manual ventilation using a bag valve device. Acad Emerg Med 1995;2:944.

26. Helling TS, Gyles NR, Eisenstein CL, Soracco CA. Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy. J Trauma 1989;29(10):1367-70.

27. Tsuno K, Prato P, Kolobow T. Acute lung injury from mechanical ventilation at moderately high air way pressures. J Appl Physiol 1990;69:956-61.


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