Thoracic injury:a review of 276 cases

Objective: Chest injury, one of the most important aspects of trauma, directly accounts for 25% of all traumarelated deaths and plays a major contributing role in another 25% of trauma deaths. This paper aimed to explore the spectrum and outcome of thoracic injuries seen in a multi centric study of trauma patients.Methods: A total of 276 consecutive trauma patients in 6 general hospitals were analyzed. The feature of injury,injury severity score (ISS), clinical treatment and mortality were recorded in a prospective manner and analyzed retrospectively. Multiple logistic regression analysis was used to determine the independent predictors of mortality following the chest trauma.Results: There were 246 males ( 89.1%) and 30 females (10.9% ) ranging from 3 to 80 years with a mean age of (34 ± 17) years. Road traffic accident was the main cause of injury, especially for pedestrians, followed by stab wound (89 cases, 32.1% ) and falling injuries (32 cases,11.6% ), respectively. Haemothorax or pneumothorax (50.4%) and rib fracture (38.6%) were the most common types of chest injury. Extremity fracture was the most common associated injury with the rate of 37% ( 85/230), followed by head injury (25.2% ) and abdominal trauma (19.6%). These injuries contributed significantly to the morbidity and mortality of trauma patients.Conclusions: According to the results, most patients with chest injury can be treated conservatively with close observation and tube thoracostomy. The presence of blunt trauma, head injury and abdominal injury independently adversely affect mortality after chest trauma. It is necessary to investigate the causes and patterns of injuries resulting from stab wound for effective prevention.

Ischemia and reperfusion injury of the spinal cord:experimental strategies to examine postischemic paraplegia

Thoracoabdominal aortic replacement,necessary in case of injuries,aneurysms and dissections,shows a high complication rate as a consequence of the perioperative ischemia/reperfusion-sequence（I/R）.Clamping above and below the lesion leads to the spinal cord suffering from ischemia.Clamping times of less than 30 minutes show only a small risk of neurological deficit,

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

Purpose:To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees’performance for emergent and urgent thoracic surgeries.Methods:With a homemade machine,animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage,urgent sternotomy,and emergent thoracotomy.Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models.Five operation teams from basic-level hospitals(group A)and five operation teams from level III hospitals(group B)were included to be trained and tested.Testing standards for the operations were established after thorough literature review,and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards.Tests were carried out after the training.Pre-and post-training performances were compared.Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.Results:Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%.After literature review,testing standards were established,and expert questionnaire results showed that the scientific score was 7.30±1.49,and the feasibility score was 7.50±0.89.Post-training performance was significantly higher in both group A and group B than pre-training performance.Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.Conclusions:Animal model-based simulation training established in the current study could improve the trainees’performance for emergent and urgent thoracic surgeries,especially of the surgical teams from basic-level hospitals.

Polytrauma with thoracic and/or abdominal injuries: experience in 1 540 cases

Objective ：To investigate the early diagnosis and treatment of polytrauma patients with thoracic and/or abdominal injuries. Methods： The data of all polytrauma patients with thoracic and/or abdominal injuries during the past 10 years were studied retrospectively. Results： In the present study, there were 1 540 polytrauma patients, accounting for 65.0% of all 2 368 trauma patients. Of these patients, 62.4% were in shock state on admission. The operative rates were 15.0% （181/1 206） and 79.9% （ 612/766 ） in patients with thoracic and abdominal injury （ P 〈 0.01 ）, 5.2 % （39/758） and 31.7% （142/448） in patients with blunt and penetrating chest trauma （P〈0.01）, and 72.4% （359/496） and 93.7 % （253/270） in patients with blunt and penetrating abdominal injuries （P〈0.01）, respectively. To deal with abdominal injury, angioembolization was performed in 43 cases, with 42 cured. The overall mortality rate was 6.2%. And in the blunt and penetrating subgroups, the mortalities were 7.9 % （75/950） and 3.6 % （21/590）, respectively （P〈0.01）. Most patients died from exsanguination. Conclusions： The first ＂golden hour＂ after trauma should be grasped, since the treatment in this hour can determine greatly whether the critically-injured victim could survive. Prompt diagnosis and proper treatment contribute more greatly to the survival of the victim than the severity of injury.

Chest injury in victims of Bam earthquake

Objective： To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science （ TUMS ） for better understanding the type and consequence of thoracic injuries in a major earthquake. Methods： After Barn earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury. Results： This group was composed of 21 females （39.6%） and 32 males （60.4%）. Fifteen patients （28.3%） had isolated chest injuries. Rib fracture （36.4 % ） was the most common injury in our patients and haemo/pneumothorax （ 25.5 % ） followed. Superficial injury was the most common accompanying injury. Multiple- trauma patients with chest injury had higher injury severity score （ISS） versus patients with isolated chest injury （P =0.003）. Conclusions： Chest wall injuries and haemo/ pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.

Management of multiple trauma with mainly thoracic and abdominal injuries： a report of 1166 cases

Objective： To discuss the diagnosis and treatment of multiple trauma with mainly thoracic and abdominal injuries. Methods： A retrospective analysis was performed on data of multiple trauma cases with mainly thoracic and/or abdominal injuries. Results： Of 1166 cases, 72.3% were found with shock. The operation rates of thoracic and abdominal injuries were 14.8% （119/804） and 83.5% （710/850） respectively （ x^2=780.683, P 〈0.01）. The operation rates of blunt and penetrating thoracic injuries was 6.8% （42/617） and 40.6% （76/187） respectively （ x^2=131.701, P〈0.01）. The operation rates of blunt and penetrating abdominal injuries were 77.1% （434/563） and 96.1% （276/287） respectively （ x^2=50.302, P〈0.01）. The operation rates of blunt thoracio-abdominal injuries were 6.8% （42/617） in thoracic region and 77.1% （434/563） in abdomen respectively （x^2=544.043, P〈0.01 ）. Among the cases of abdominal injuries, 41 received arteriography embolism, with the efficacy of 95.1% （39/41）. Total mortality rate was 6.1%. The mortality rates of blunt and penetrating injuries were 7.3% （62/854） and 2.9% （9/312） （ x^2=6.51, P〈0.005）. The deaths were mainly due to large volume of blood loss. Conclusions： When both thoracic and abdominal injuries exist, laparotomy is frequently required rather than thoracotomy. Laparotomy is seldomly used for blunt thoracic injuries, but usually used for penetrating thoracic and abdominal injuries. Mortality rate of penetrating thoracic and abdominal injuries is markedly lower than that of blunt injuries. Surgical operation is still important for those patients with penetrating thoracic or abdominal injuries.

Damage control surgery for severe thoracic and abdominal injuries

Objective: To investigate the application of damage control surgery in treatment of patients with severe thoracic and abdominal injuries.Methods: A retrospective study was done on 37 patients with severe thoracic and abdominal injuries who underwent damage control surgery from January 2000 to October 2006 in our department. There were 8 cases of polytrauma ( with thoracic injury most commonly seen), 21 of polytrauma (with abdominal injury most commonly seen) and 8 of single abdominal trauma. Main organ damage included smashed hepatic injuries in 17 cases,posterior hepatic veins injuries in 8, pancreaticoduodenal injuries in 7, epidural or subdural hemorrhage in 4,contusion and laceration of brain in 5, severe lung and bronchus injuries in 4, pelvis and one smashed lower limb wound in 3 and pelvic fractures and retroperitoneal hemorrhage in 6. Injury severity score (ISS) was 28-45 scores (38.4 scores on average), abbreviated injury scale (ALS) ≥ 4.13. The patients underwent arteriography and arterial embolization including arteria hepatica embolization in 4 patients, arteria renalis embolization in 2 and pelvic arteria retroperitoneal embolization in 7. Once abbreviated operation finished, the patients were sent to ICU for resuscitation. Twenty-four cases underwent definitive operation within 48 hours after initial operation, 5 underwent definitive operation within 72 hours after initial operation, 2 cases underwent definitive operation postponed to 96 hours after initial operation for secondary operation to control bleeding because of abdominal cavity hemorrhea.Two cases underwent urgent laparotomy and decompression because of abdominal compartment syndrome and 2 cases underwent secondary operation because of intestinal fistulae (1 case of small intestinal fistula and 1 colon fistula) and gangrene of gallbladder.Results: A total of 28 patients survived, with a survival rate of 75.68%, and 9 died (4 died within 24 hours and 5 died 3-9 days after injury). The trauma deaths at the early stage were caused by severe primary injuries resulting in failure of respiration and circulation, while mortality at the later stage was caused by multiple organ failure.Conclusions: Damage control surgery is important for the treatment against severe thoracic and abdominal injuries. It is suggested that the surgeon should select the reasonable auxiliary examination before operation, and take the proper time to perform damage control and definitive surgery.

Use of bronchofiberscopy in management of severe thoracic trauma

Objective： To investigate the diagnos- tic and therapeutic effect ofbronchofiberscopy in the manage- ment of severe thoracic trauma. Methods： A retrospective study was conducted on 207 consecutive patients with severe thoracic trauma enrolled in our hospital between January 2008 and June 2012. During the period, 488 bronchofiberscopies and lavages were done. The bronchofiberscope was inserted through tracheal inci- sion （282）, nasal cavity （149） and oral cavity （57）. Intensive SaO2 monitoring as well as blood gas analysis were per- formed pre-, intra- and postoperatively. Simultaneously oxy- gen therapy or ventilatory support was given. Sputum cul- ture was done intraoperatively. Results： Diagnosis in 207 cases was confirmed by bronchofiberscopy. The result of sputum culture was posi- tive in 78 cases. Lavage was performed on 156 cases. SaO2 significantly increased after bronchofiberscopies as well as lavages and PaO2 obviously improved 2 h after surgery （both P〈0.05）. Heart rate and respiratory rate decreased. There was no bronchofiberscopy-related death. Conclusion： Bronchofiberscopy plays an important role in the diagnosis and treatment of severe thoracic trauma, which can not only timely diagnose bronchial injury and collect deep tracheal sputum for bacterial culture but also effectively remove foreign body, secretion, blood and spu- tum crust in the airway, manage obstructive atelectasis and pneumonia, and signifcantly improve respiratory fimction and treatment outcome.

Traumatic cardiac injury： Experience from a level-1 trauma centre

Purpose： Traumatic cardiac injury （TCI） is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status, The current study is to evaluate the factors influencing the outcome of TCI. Methods： Prospectively maintained database of TCI cases admitted at a Level-I trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15. Results： Out of 21 cases of TCI, 6 （28.6%） had isolated and 15 （71.4%） had associated injuries. Ratio be- tween blunt and penetrating injuries was 2：1 with male preponderance. Mean ISS was 31.95. Thirteen patients （62%） presented with features suggestive of shock. Cardiac tamponade was present in 12 （57%） cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery, Perioperatively 8 （38,1%） patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest （p = 0.014）, arrhythmia （p = 0.014）, and hemorrhagic shock （p = 0.04）. The diagnostic accuracy of focused assessment by sonography in trauma （FAST） was 95.24%. Conclusion： High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Characteristics and outcome of traumatic chest injury patients visited a specialized hospital in Addis Ababa, Ethiopia: A one-year retrospective study

Purpose: Injury continues to be an important cause of morbidity and mortality in both developed and developing countries. Globally, it is responsible for approximately 5.8 million deaths per year and 91% of these deaths occur in developing countries. Road traffic collision, suicides and homicides are the leading cause of traumatic deaths. Despite the fact that traumatic chest injury is being responsible for 10% of all trauma-related hospital admissions and 25% of trauma-related deaths across the world including in Ethiopia, only few published studies showed the burden of traumatic chest injury in Ethiopia. So, this study aims at assessing the characteristics and outcome of traumatic chest injury patients visited Tikur Anbesa Specialized Hospital (TASH) over one year period.Methods: A single center based retrospective study was done. We collected data from patients’ records to assess characteristics and outcome of traumatic chest injury at TASH over one year period. All patients diagnosed with traumatic chest injury and received treatment at the hospital from January 1 to December 31, 2016 regardless of its types and severity levels were included in the study. Patients with incomplete medical records for at least 20% of the study variables and without detailed medical history, or patients died before receiving any health care were excluded from the study. The collected data were cleaned and entered into Epidata version 3.1 and exported to SPSS Version 21.0 for analysis. Bivariate and multivariate logistic regression models were used to examine factors associated with outcome of trau- matic chest injury patients.Results: A total of 192 chest injury patients were included in the study and about one-fourth of chest injury victims were died during treatment period in TASH. Road traffic collision (RTC) was the leading cause of morbidity and mortality among traumatic chest injury victims. Age of the victims (adjusted odds ratio (AOR) 8.9, 95% confidence interval (CI) 1.51-53.24), time elapsed between the occurrence of traumatic chest injury and admission to health care facilities (AOR 4.6, 95%CI 1.19-18.00), length of stay in hospital (AOR 0.12, 95%CI 0.02-0.58), presence of multiple extra-thoracic injury (AOR 25, 95%CI 4.18-150.02) and development of complications (AOR 23, 95%CI 10-550) were factors associated with death among traumatic chest injury patients in this study.Conclusion: RTC contributed for a considerable number of traumatic chest injuries in this study. Old age, delay in delivering the victim to health care facilities, length of stay in hospital, and development of atelectasis and pneumonia were associated with death among traumatic chest injury patients. Road safety interventions, establishment of organized pre-hospital services, and early recognition and prompt management of traumatic chest injury related complications are urgently needed to overcome the underlying problems in the study setting.

Unusual management of thoracoabdominal impalement injury to the right hemiliver and diaphragm

Laparotomy or thoracolaparotomy is a traditional management approach for thoracoabdominal im- palement injury associated with major liver and diaphrag- matic injuries. We successfully treated the impalement in- jury with minimally invasive management. A male was brought to our trauma centre with the 15 cm long handle of the knife protruded from right lateral thoracoabdominal region. CT scan revealed that the knife blade traversed through the right costophrenic recess into segment 8 of the liver. There was an intraparenchymal haematoma and a col- lection of fluid in the abdominal cavity. The conservativemanagement plan consisting of removing the impaled knife, observing, monitoring and managing complications was undertaken. A multidisciplinary approach to manage a pa- tient with less invasive techniques yielded a good outcome. This management option may be considered as an alterna- tive for open surgery for hemodynamically stable patients in experienced centres.

Rare case of impalement of two occupants of a vehicle by the same object： insights into the management of complex thoracic impalements

Thoracic impalement injuries are very rare and the majority of patients do not survive to reach a medical care facility.In this case report,we describe the successful outcome of a case of double thoracic impalement by two steed tors,of which one steel tor had impaled two patients simultaneously.The case report highlights all aspects of managing such rare and complex cases right from prehospital care; extrication process which happened under controlled environment at the trauma centre itself,till the definitive management of the impaled thoracic objects.Thoracic impalement injuries are dramatic and appear very challenging.However presence of mind of the managing team,coordinated team effort and availability of adequate facilities can lead to a successful outcome.

The dynamic response of heart and its injury involving chest impact

Objective: The dynamic response of the heart during chest impact and the characteristics of heart injuries were investigated to further understand the mechanisms of heart impact injuries. Methods: Eleven dogs and thirty four rabbits were subjected to front thoracic impact with different impact velocities and compression response. The accelerated movement of thoracic wall during the impact period was monitored. The pathological examination of the injured heart was done and the dynamic responses and mechanisms of injuries were analyzed with mathematics models. Results: The analysis of mathematics model and experimental results showed that the injury severity of heart was well correlated with the viscous criterion. The thoracic wall was involved in bi directional movement of compression and expansion. The injured heart showed spotty or stripy hemorrhages in the ventricle endocardium. Light microscopic examination showed interstitial bleeding and rupture of the myocardial fibers in the contusion area. The biomechanical analysis indicated that there was a large deformation caused by the stress concentration on the lateral ventricle wall. Conclusions: There is a high speed and excessive deformation of the heart during the impact period, which might be the key mechanism of heart injury. The strong impact and press coming from both sternum and vertebral column and the rapid elevation of pressure in the ventricle are the main cause of deformation.

Effect of seawater immersion on plasma osmotic pressure and electrolyte balance following open chest trauma

Objective: To explore the effect of seawater immersion on serum osmotic pressure and electrolytes balance following chest trauma in dogs. Methods: Twenty five healthy adult dogs were used in the experiment. A canine model of right open pneumothorax was established by chest puncturing on all animals. Animals were divided into three groups: a control group (n=10) with chest trauma without any immersion; a seawater group (n=10) immersed in seawater after chest trauma and a normal saline group (n=5) immersed in normal saline solution following chest trauma. Blood samples were taken at different time intervals to determine plasma osmotic pressure and electrolytes. The hemodynamic changes were also recorded. Results: Mortality in the seawater group was much higher than that of the control group and the normal saline group. The mean survival time in the seawater group lasted only 45 minutes, while in the control group and the normal saline group the average survival time was more than 4 hours (P< 0.01 ). One of the most important causes of death was hypernatremia and high osmolality. Severe electrolytes imbalance was observed in seawater group. Hypernatremia and high osmolality were the most significant factors of high mortality in the seawater group. Conclusions: Seawater immersion after chest trauma appears to be associated with severe electrolyte imbalance as well as high osmotic pressure. These may be the risk factors leading to fatal outcome.

Surgical treatment of posttraumatic foreign bodies in the heart or great vessels

Posttraumatic foreign bodies in the heart or great vessels is rare, which may cause cardiac tamponade, bleeding, shock, infection, embolism, arrhythmia, valve dysfunction, etc.13 The foreign bodies can be removed by surgery or percutaneous intervention.4 In this report we reviewed our experience in managing posttraumatic foreign bodies in 13 patients at our institution from 1992 to 2002.

Treatment of 336 cases of chest trauma

Objective： To summarize the clinical features, diagnosis and treatment of chest trauma. Methods： A retrospective analysis was conducted among 336 cases of chest trauma admitted to our hospital from January 2009 to May 2011. Results： Out of all cases, 325 were cured, accounting for 96.7%; 11 died, accounting for 3.3%. Among the dead cases, one died of hemorrhagic shock, three of acute respiratory distress syndrome, three of multiple organ failure, and four of severe multiple traumas. Conclusions： （1） For patients with severe chest trauma, early emergency treatment is crucial to save life. （2） Open thoracic surgery is needed for acute cardiac tamponade, intrapulmonary vascular injuries, progressive intrathoracic bleeding, lung laceration, tracheal breakage, and diaphragmatic injury. In addition, operative timing and method should be well chosen. （3） Pulmonary contusion is one of common complications in chest trauma, for which the combination of strong anti-infection therapy and mechanical ventilation is an effective treatment strategy.

Analysis of high risk factors related to acute respiratory distress syndrome following severe thoracoabdominal injuries

Objective: To investigate the high risk factors related to acute respiratory distress syndrome ( ARDS ) following serious thoracoabdominal injuries.Methods: The clinical data of 282 patients with serious thoracoabdominal injuries were retrospectively studied. Univariate and Cox multivariate regression analysis were used to determine the risk factors related to ARDS following serious thoracoabdominal injuries.Results: The incidence of ARDS was 31.9% (90/282) in patients with serious thoracoabdominal injuries.The mortality caused by ARDS was 37.8% (34/90). The univariate analysis and multivariate analysis demonstrated that the clinical conditions such as elder age, shock,dyspnea, abnormal arterial blood gas, hemopneumothorax,pulmonary contusion, flail chest, coexisting pulmonary diseases, multiple abdominal injury and high ISS score were the independent high risk factors related to ARDS.Conclusion: There are many high risk factors related to ARDS following severe thoracoabdominal injuries, which should be detected early and treated timely to decrease the incidence and mortality of ARDS.

Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma

Objective：Thoracic injuries are responsible for 25% of deaths of blunt traumas.Chest X-ray （CXR） is the first diagnostic method in patients with blunt trauma.The aim of this study was to detect the accuracy of CXR versus chest computed tomograpgy （CT） in hemodynamically stable patients with blunt chest trauma.Methods：Study was conducted at the emergency department of S ina Hospital from March 2011 to March 2012.Hemodynamically stable patients with at least 16 years of age who had blunt chest trauma were included.All patients underwent the same diagnostic protocol which consisted of physical examination,CXR and CT scan respectively.Results：Two hundreds patients （84% male and 16% female） were included with a mean age of（37.9±13.7） years.Rib fracture was the most common finding of CXR （12.5%） and CT scan （25.5%）.The sensitivity of CXR for hemothorax,thoracolumbar vertebra fractures and rib fractures were 20%,49% and 49%,respectively.Pneumothorax,foreign body,emphysema,pulmonary contusion,liver hematoma and sternum fracture were not diagnosed with CXR alone.Conclusion：Applying CT scan as the first-line diagnostic modality in hemodynamically stable patients with blunt chest trauma can detect pathologies which may change management and outcome.

Outcomes of surgical management of tracheobronchial injuries a case series from a developing country

Objective： Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma. Methods： A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries. Results： The average age was 3 l years with most of the patients being male （14：1）. Among them,11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma （blunt and penetrating trauma）. Eightpatients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% （1 patient）. Most patients survived with no sequelae （10 patients） while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management. Conclusions： Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.

Brachiocephalic trunk and left brachiocephalic vein injuries following penetrating right sternoclavicular junction trauma： a case report

A 46-year-old male sustained severe pe- netrating injury by a sharp instrument to his right upper sternoclavicular junction. The wound tract was from su- prasternal notch to mediastinum. Exploratory operation via median sternotomy under general anesthesia found a large mediastinal septum hematoncus, as well as brachiocephalic trunk and left brachiocephalic vein injuries. The perforating vascular wounds were repaired with 5-0 prolene suture. He was recovered uneventfully and discharged 9 days after operation. There was no sequel found during 7 years fol- low-up.