Chest trauma (or thoracic trauma) is one of the most. Analytic Study of Chest Injury. Original Article. Jigar V Shah 1, Mehul I Solanki 2.

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1 DOI: /SUR/2015/03 Analytic Study of Chest Injury Original Article Jigar V Shah 1, Mehul I Solanki 2 1 Associate Professor, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India, 2 Resident, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India Abstract Background: Trauma is one of the leading causes of morbidity and mortality worldwide. Chest trauma constitutes about 10-15% of all cases and is responsible for 25% of deaths as a result of trauma. It is a major problem for India, where there is a very high incidence of vehicular accidents (6% of global vehicular accidents), along with crime and riots. In spite of that very few studies have been documented that assess the prevalence and management of these events. Hence, this retrospective study was carried out to determine the magnitude and management of patients with chest trauma in rural setup. Methods: A study of 100 cases of chest trauma admitted in Dhiraj Hospital, from May 2010 to September 2012 was carried out. The data collected included the patient s demographic profi le; mode, type and severity of chest injuries, management scheme and outcome. Results: Of 100 patients who sustain chest trauma, 76% of cases were due to vehicular accident. Of 100 patients 64% had rib fractures, 17% had fl ail chest, 12% had pneumothorax, 24% had hemothorax, and 5% had hemopneumothorax and 24% had extra-thoracic injury. In 33% water seal intercostals tube insertion was done and 17% of patients having fl ail chest were treated with intermittent positive pressure ventilation. Conclusions: The present study reveals that the trauma commonly seen in young males was motor vehicle accident. The outcome and prognosis for the majority of patients of blunt chest trauma are excellent. Most require no invasive therapy or, at most intercostals chest drainage tube insertion. Keywords: Fracture, Pain, Rib, Trauma INTRODUCTION Chest trauma (or thoracic trauma) is one of the most serious injuries of the chest and also a common cause of significant disability and mortality. It is also the leading cause of death from physical trauma after head and spinal cord injury. Thoracic injuries are found to be the primary or a contributing cause of about a quarter of all trauma related deaths. The mortality rate in these cases is about 10%. 1 Thoracic injuries account for 20-25% of deaths due to trauma. Approximately, 16,000 deaths per year in India alone are a result of chest trauma. 2 The increased prevalence of penetrating chest injury and Access this article online Month of Submission : Month of Peer Review : Month of Acceptance : Month of Publishing : improved pre hospital and intra operative care have led to increasing number of critically injured but potentially salvageable patients presenting to trauma center. Chest trauma contributes to major accidental injuries in India, due to increased incidence of vehicular accidents (6% of global vehicular accidents) due to increased road traffic, availability of new high-speed vehicles, and ignorance or unawareness of traffic rules. 3,4 A very few studies have been conducted to analyze its magnitude and management in Indian scenario. This study is carried out to determine the epidemiology of the etiology of chest trauma along with analyzing the management scheme and to note the prognosis and scope of improvement of chest injuries in a rural set up. In India, other causes of chest injuries are falling off the roof or wall of old houses, injuries due to increased construction activities, fall in well, injuries by cattle, violence, etc. However, it is now expected that injury by automobile accidents will decrease to some extent with the advancement in automobile technology equipped with air bags and seat belts and increased traffic rules awareness. The subject of the chest Corresponding Author: Dr. Jigar V Shah, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India. jigarshah2225@yahoo.in IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1 5

2 trauma is of vital importance in the warfare surgery. 5-8 With a rise in political tension all over and increasing inter racial violence; it is imperative that the surgeon should be apprised of war injuries due to bombs, blasts, stones, etc. which may cause injury to the internal organs without injuring the body surface. But with rapid industrialization of cities and tremendous increasing in the high-speed traffic flow we will have to face the problems arising from this and one of the problems would be chest injury. Sometimes, the most difficult decision facing the surgeon is the allocation of the priorities in the treatment when more than one body system has been injured. Head injury, compound limb fracture and chest injury competes for the surgeon s attention. Chest injury is potentially the most dangerous of all and its management should be a matter of the most extreme urgency. The particular danger of the chest injury is that it threatens the vital transport of oxygen to the tissue by two ways: By hypovolemia from severe bleeding and by trauma to the lung itself. Even this hypoxia is danger to life; it can adversely influence the outcome of associated brain trauma. At the same time, advancement in anesthesia has offered safety of operation within chest Blood transfusion services, volume-cycled and pressure cycled respirators, antibiotics, X-rays, ultrasonography, tomography, computed tomography, radionuclide lung scan, underwater seal intercostal drainage, tracheostomy, blood gas analysis, spirometry, oesophagoscopy, bronchoscopy and dionosil swallow have remarkably improved the results of critically ill-patients. Physiotherapy, rehabilitation has also added to the improvement in management of chest injuries. In thoracic trauma, primary care is directed to the rapid evaluation of extent of injury, estimation of volume of blood loss and its rapid replacement by intravenous transfusion, the recognition of hypoxia and respiratory distress and its correction by assurance of a clear airway, full pulmonary expansion and mechanical support of ventilation when necessary. The vast majorities of chest trauma patients do are successfully managed by intercostals tube drainage and do not require thoracotomy METHODS A study of 100 cases of chest trauma admitted in Dhiraj Hospital, from May 2010 to September 2012 has been carried out. The study was pertaining to both blunt and penetrating chest trauma. The cases were followed for at least 3 months and some cases were followed for 6-8 months according to the necessity and post-mortem examination was carried out in most of the cases that expired, to elucidate the cause of death. The time of injury with its mechanism of and evidence of associated injury to other system (e.g. loss of consciousness), are all salient features of an adequate clinical history. Information was obtained directly from the patient whenever possible and from other witness of the accident if available. Initial work-up of the patients with multiple injuries was started with the ABCs of trauma with appropriate intervention taken for each step. Additional workup includes the following. Chest radiograph, complete blood count, serum investigation, blood grouping and cross matching, ultrasonography of chest and abdomen, computed tomography of the head, other radiological investigation and if required rigid bronchoscopy was done. All the patients were admitted in the casualty ward or other general surgical ward according to the nature of the injury. Those patients who were discharged against medical advice were excluded from our study. Inclusion and exclusion criteria Inclusion criteria: Only those patients who were willing to participate in the study were included. Patients who came to the casualty with chest trauma and associated polytrauma were included in the study. Medico-legal cases were also included in the study. Exclusion criteria: Patients not willing to give consent and patients who were discharged against medical advice were not included in the study. RESULTS The outcome of the study is enchanted in form of facts in the tables, they are self-explaining. Tables 1-9, show the outcome of the study and it compares the results from the study with the existing result that is documented in the literature. DISCUSSION This is the age of multisystem injury, among multiple injuries, the chest trauma is potentially the most dangerous of all, and its management is of extreme urgency where life saving measures can be practical at road side. Chest Table 1: Comparison of incidences of chest trauma Blunt chest trauma Penetrating chest trauma Ozgen and Duygulu 949 (65.4) 504 (34.7) ( ) 5 Kulshrestha et al. 149 (63.1) 87 (36.9) (January 1983-July 1985) 3 Bispebjery Hospital 181 (80.6) 75 (9.3) ( ) 4 Our study 95 (16.25) 5 (0.41) 6 IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1

3 trauma is responsible for one-fourth of all deaths in the United States. 1 It also contributes significantly to the lethal outcome although the relative contribution of chest injury to mortality after trauma victim have reached to the hospital ward is small. 2 With rapid industrialization of cities, urbanization, and tremendous increase in high speed traffic flow, trauma in general and chest trauma in particular are on increase, requiring augmented care, trained personnel and sophisticated equipment for saving the life of these patients. This study consisting of 100 cases of blunt chest trauma treated at Dhiraj Hospital was initiated in order to analyze them in context of etiology and factors relating to treatment and management of patients. Chest trauma forms 8.33% of Table 2: Comparison of median age in chest trauma patients Median Sex age (years) Male Female Shorr et al Kulshrestha et al Ramussen and Brinitz Our study Table 3: Comparison of etiology of chest injury Vehicular accidents Others Shorr et al Ramussen and Brinitz Clark, Schechter et al Johnson, Bill et al Kulshrestha et al Our study Table 4: Comparison of the site of injury in chest trauma Right Left Both Stumm and Perry Kulshrestha et al Our study total no. Of traumatic cases admitted to the institution during the same period. In western countries, there are varying incidences on the occurrence of chest trauma most of the data obtained are from specialized trauma centers where the selection of samples would be biased one. The study conducted at All India Institute of Medical Sciences Kulshrestha et al. (January 1983-July 1985) shows that chest trauma constitutes 5.3% of all trauma patients (236/4434) where a blunt chest trauma constitutes 3.35% of all trauma patients (149/4434). 3 The study conducted by Shorr et al. in 1982, 1984 at MIEMESS shock trauma center showed that chest trauma forms 9.5% of all trauma cases (515 out of 5378). They also state that the chest trauma is directly responsible for 25% of all traumatic death that occurs annually. 4 In our study during the same period there were 5 cases of penetrating chest trauma out of a total of 100 cases. It can be consistently seen from the foregoing discussion that blunt chest traumas are definitely commoner than their penetrating counterpart. However, D abrve has stated that the type of injury encountered within a geographical area depend upon the civilization of the society, culture, and industrialization. Thus in several African tribes penetrating injuries are common up to the ratio of 3:1. Incidence of penetrating injuries in the present study was low. Though, A higher incidence rate (43%), was reported by Beg et al., in India, which could have been due to a higher prevalence of violence in the study area. No age is immune to chest trauma. In our study age of patient varies from 9 to 75 years. Majority of patients (52%) were in age group of years. Whereas about (70%) of patients were in age group years, there were only 2 patients below 10 years and only 2 patient above the age of 70 years. Shorr et al. in their study at MIEMSS shock trauma center found the mean age of the affected patients. 4 Table 5: Comparison of associated injury in chest trauma patients Head injury Extra thoracic fracture Abdominal trauma Spinal injury and other Mortality Shorr et al Kulshrestha et al Ramussen Our study Table 6: Comparison of different injuries in chest trauma patients Sternal fracture Fracture clavicle Flail chest Fracture scapula Haemopnumothorax Haemothorax Kulshrestha et al Ramussen et al Shorr et al bil. Laustelia Our study bil. IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1 7

4 Table 7: Comparison between modes of treatment in chest trauma Operative Conservative Kulshrestha et al Ramussen et al Shorr et al Dalal et al Mandke et al Our study 4 96 Table 8: Comparison of ICD in chest trauma patients Intercostal drainage Kulshrestha et al % (85/149) Ramussen et al. 5 60% (56/93) Shorr et al % (287/515) Our study 33% (33/100) Table 9: Comparison of complications of chest trauma Complication Stum Shorr et al. Ramussen Our study Empyema Pneumonia Atelectasis ARDS Pericardial effusion Emphysema Recurrent Recurrent Death ARDS: Acute respiratory distress syndrome Males are far more frequently affected than females as reflected as per the data. In our study vehicular accidents formed a significant portion (76%) of blunt chest trauma, followed by fall from height (16%) and assault in (3%) cases. In our study, 52% of cases had trauma to the right side of the chest, 44% had trauma on the left side and 4% had injury on both sides of the chest. Associated injuries with blunt chest trauma can be the head injury, abdominal trauma, injury to extremities, spinal injury or pelvis injury. Management of chest trauma consists of various procedures and observations of the patient. Modalities of management may be conservative or operative. Conservative management: Most of the patients with blunt chest trauma can be treated with conservative methods, very few requiring operative management in the form of thoracotomy. In our series most of the patients (96%) were managed by the conservative line of management. The conservative line of management may be in the form of relief of pain by analgesics, sedation, nerve block and strapping. For the treatment of associated shock, intravenous fluids, blood transfusion and oxygen were required. Respiratory resuscitation is one of the most important aspect of management of chest trauma, for which airway must be kept patent and if required endotracheal intubation or tracheostomy is to be done. Intercostal tube drainage is also a part of conservative management. It decompresses the pleural cavity from the blood/air and helps in expansion of lungs. For the management of flail chest tracheostomy, strapping and traction by towel clips are required. CONCLUSION Chest trauma is one of the major and serious injuries following vehicular accident. They contribute significant to both mortality and morbidity but with concepts about management becoming increasing clear, there is declining mortality rate. Intercostal tube drainage with under seal is an acceptable and safe management for management for patient having pneumothorax, hemothorax, or hemopneumothorax. Simple rib fracture is best managed by analgesics and in some patients with strapping and intercostals nerve block. Every patient with chest trauma is to be checked for respiratory distress and patency of airway must be maintained before going for other pathology. Skeleton traction along with strapping and tracheostomy remains the procedure of choice for management of flail chest where positive pressure ventilation is not easily available. The outcome and prognosis for the majority of chest trauma are excellent. Majority of these cases (>80%) require either no invasive therapy or may require an intercostal tube drainage at most. Some injuries, as in cardiac chamber rupture, thoracic aortic rupture, injuries of the intrathoracic inferior and superior vena cava and delayed recognition of esophageal rupture are associated with high morbidity and mortality rates. REFERENCES 1. Wison RF, Murray Antonio DR. Non penetrating thoracic injury. Surg Clin North Am ;57: Locicero J, Mantox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69: Kulshrestha P, Iyer KS, Das B, Balram A, Kumar AS, Sharma ML, et al. Chest injuries: A clinical and autopsy profile. J Trauma 1988;28: Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206: Rasmussen OV, Brynitz S, Struve-Christensen E. Thoracic injuries a review of 93 cases. Scand J Thorac Cardiovasc Surg 1986;20: IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1

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