Introduction

The chest is frequently injured by both, penetrating and blunt trauma with a spectrum of injuries ranging from a simple rib fracture to severe vital organ injuries. The vast majority of chest trauma patients do not require thoracotomy and are successfully managed by tube thoracostomy.

The approach to diagnosis and treatment of injuries to the chest depends greatly on the mechanism of injury and the evidence and type of associated injury.

We reviewed our recent experience with chest trauma in Gülhane Military Medical Academy (GMMA), Thoracic Surgery Department.

Material and Methods

Between 1994 and 1999, 336 patients with injuries to the chest were hospitalised at the Thoracic Surgery Department in GMMA. Of these 336 patient, 25 were female and 311 were male (female/male ratio: 1/ 12.4). The median age was 30.5 (range from 20 to 69).

177 patients had a blunt chest trauma and 159 patients had a penetrating chest trauma.

The causes of injury in the blunt trauma group were traffic accidents in 92 and fall or sport accidents in 85. The causes of injury in the penetrating trauma group were gunshot wounds (including shrapnel and mine) in 140 and stab wounds in 19 patients (Table I).

Figure 1

Table 1: Causes of Injury

The frequency of chest lesions was as follows:

Blunt trauma group: Pneumothorax 37, hemothorax 51, hemopneumothorax 11 and varied fracture without complication (rib, clavicle, and sternum) 78 cases.

Penetrating trauma group: Pneumothorax 45, hemothorax 73, hemopneumothorax 34 and penetrating trauma without complication 7 cases (Table II).

Figure 2

Table II: Frequency of Thoracic Complications

The frequency of associated injuries outside the thorax was as follows:

Abdominal injuries, 28, injuries to lower extremities, 41, cranial injuries, 35, peripheral vascular injuries 8 and vertebral body fracture 3 patients (Table III).

Figure 3

Table III: Associated Injuries

Results

The most common therapeutic procedure was pleural drainage in 99 (55.9%) patients of the blunt trauma group and 152 (95.5%) of the patients in the penetrating trauma group.

A chest drain was inserted 251 of 336 patients (74.7%). We have three (0.89 %) early mortalities in patients who had a chest drain.

Two patients in the blunt trauma group required an early thoracotomy (1.12%) (wedge resection for one patient and inter costal artery ligation for the other patient).

In the penetrating trauma group, three (1.88%) patients underwent a thoracotomy (lobectomy for one patient, wedge resection for one patient and primary parenchymal repair for the last patient). No mortality was reported in any of these cases.

An empyema developed in two (0.59 %) cases and one of them underwent an early decortication (0.29 %).

Three patients with vertebral fractures, 1 patient with mastoid hematoma and 2 patients with mastoid fractures had to go to surgery. Peripheral vascular operations were performed in 8 patients. The most common associated injuries were lower extremity injuries and abdominal injuries. Treatments for associated abdominal injuries are shown in table IV.

Figure 4

Table IV: Treatment for associated abdominal injuries

Discussion and Comments

Trauma is known to be a leading cause of death in the first four decade of life. Statistics regarding the true incidence of chest trauma are scant (₁).

It has been estimated by Lo Cicero and Mattox (1989) that 20 to 25 % of trauma deaths, and approximately 16 thousands deaths per year, are attributable to thoracic injuries in the United States.

In the western population, blunt trauma from motor vehicle accidents has accounted for 70 to 80 % of thoracic injuries (₂).

It appears that chest wall injury accounts for over 50 % of all thoracic injuries, with pneumothorax or hemothorax occurring in 40 to 45 % (1,2,₃).

Prior to 20th century, the mortality rate for penetrating wounds of the chest exceeded 50%. Since no significant civilian series were reported, one must look to military campaigns for a tabulation of mortality. Many of the current management principles of thoracic injuries were gained from the military conflicts in World War II and South Asia, in which more than 90 percent of the casualties were from penetrating wounds (₄).

The declining mortality occurred in spite of improved transportation, allowing a higher percentage of critically injured patients to reach the hospital alive.

In civilian practice, it has been known that supportive measures (protecting airway, stopping bleeding and restoring circulating blood volume) and tube thoracostomy are sufficient in treating about 70-80% of trauma victims (₅,₆).

Thoracotomy is required only for massive bleeding, severe air leak or injury to the great vessels, trachea-bronchial tree or oesophagus and post-traumatic empyema (₇).

Blunt injuries to the chest have a higher mortality than penetrating injuries because they are more massive and have a higher incidence of multiple systemic damage (5).

The percentage of treatment without operation (regarding thoracotomy) was 98.5 % (331 patients) in our series. The rate of operations reported in the literature for penetrating injuries is about 2 to 25 % (7,₈).

Associated extra thoracic injuries have been reported in the literature to be 50 to 75 % (2,3). (34.2 % in our series)

Previous reports of pulmonary resection for lung trauma have shown a high mortality. The reported overall mortality ranged from % 12 to 50 (5).

The location of penetrating wounds should be noted. If the wound is located below the fifth rib, evaluation of abdomen is necessary because the possibility of diaphragmatic penetration. Intra-abdominal injuries must be excluded.

In hemodynamically unstable patients with multiple injuries that involve the chest and abdomen, we recommend laparotomy as the first intervention (if there is an evidence of pneumothorax or hemothorax, we only insert a chest drain later during the laparotomy).

In our practice, thoracotomy is indicated if the initial chest tube output is greater than 1500 ml or if the hourly output continues at greater than 200 ml/hour for three hours.

If inflation of the lung fails to control pulmonary parenchymal bleeding, the patient may require pulmonary resection. In patients with large pulmonary lacerations, contusion and significant bleeding, haemorrhage can be controlled with standard anatomic lobar or segmental resection.

In all cases, the extend of resection should be as conservative as possible, and according to the anatomic boundaries if feasible.

The incidence of empyema following thoracic trauma is approximately 3 to 5 % (⁹). Blood in the pleural space is a rich culture media that promotes bacterial growth in spite of antibiotics, pulmonary toilet, and tube thoracostomy. Treatment of posttraumatic empyema must accomplish two objectives: complete reexpansion of the underlying lung and evacuation of all infected blood from the pleural space. Multiple tube thoracostomies are initially attempted, but failure to achieve these two objectives within a few days is an indication for thoracotomy and decortication.

Conclusions

Thoracotomy and pulmonary resection are infrequently required for lung trauma. Tube thoracostomy and supportive measures successfully manage the vast majority of chest traumas. Other organs or systems should be carefully assessed for associated injuries.