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SciFed Journal of Surgery Chest Trauma: A Tertiary Center Experience

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 Mohamed Alassal, SF J Surgery, 2017, 1:2

SciFed Journal of Surgery

Research Article Open Access

Chest Trauma: A Tertiary Center Experience

*1,2
Mohamed Alassal, 1Hany Elrakhawy, 1Mohamed Saffan, 1Ehab Fawzy, 1Moataz Rizk, 1Mohamed Elgazzar,
1
Basem Mofreh, 5Ayman Ghoniem, 6Anwar Amin, 1Yousry El-Saead, 1Yousry Shaheen, 1Mahmoud Elemam,
3,4
Bedir Ibrahim
1
Cardiothoracic surgery department, Benha university hospitals, Benha, Egypt
2
PAAMCC, Arar, KSA 3Cardiothoracic surgery department, Tanta university hospitals, Tanta, Egypt
4
Al-iman hospital, Riyadh, KSA
5
Cardiothoracic surgery department, Alazhar university hospital, Egypt
6
Cardiothoracic surgery department, Assiut university hospital, Egypt

Abstract
Road traffic accidents (RTA) and Thoracic trauma is one of the leading causes of morbidity and mortality in
developing countries. In this retrospective study, we present our three year experience in the management and clinical
outcome of 1700 cases with chest trauma associated with blunt and penetrating injuries in two tertiary centers (in
Egypt and Saudi Arabia). In 66% of the cases, blunt injury mostly related to traffic accidents was the cause of chest
trauma. Additional organ injuries were found in 45% (n=766). Conservative treatment was administered for most
patients. Tube thoracostomy was inserted in 82.2% of all cases, whereas thoracotomy was performed in 9% (n=156).
The morbidity rate in all victims was 22.2%. The mortality rate was 2.1% of all patients, all were blunt trauma with
associated other injuries. Mortality and injury severity score (ISS) increased in patients having early surgery. Although
most patients could be managed with conservative approaches, early thoracotomy was required in some cases. We
believe that urgent hospital admission, early diagnosis, and multidisciplinary approach are very important to improve
outcome.

Keywords problems in daily human practice especially due to

Chest Trauma; Blunt Trauma; Penetrating Trauma;
Thoracotomy
Introduction
Thoracic injury is a common cause of mortality
and major disability, and the leading cause of death
from physical trauma after head and spinal cord injury
[1]. Thoracic injuries account for 20-25% of deaths due
to trauma. Penetrating thoracic trauma accounts for almost
33% of total chest trauma [2] Thoracic trauma associated
with blunt or penetrating injury is a major cause of
hospitalization in the world and is associated  with
a mortality rate ranging from 15 to 77%  [3].
Thoracic trauma comprises 10-15% of all trauma and
represents 25% of all mortalities due to trauma [3, 4].
Blunt chest injuries are among the most important
the increasing incidence of traffic accidents especially
in developing countries. The chest wall and the soft
tissues are the locations most commonly affected by
*Corresponding author: Mohamed Alassal, Cardiothoracic surgery
department, Benha university hospitals, Benha, Egypt. E-mail:
dmohamedabdelwahab@gmail.com Telephone No: +966539417103
Received September 18, 2017; Accepted November 6, 2017; Published
November 15, 2017
Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center
Experience. SF J Surgery 1:1.
Copyright: © 2017 Mohamed Alassal. This is an open-access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.

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 Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center Experience. SF J Surgery 1:1.
blunt trauma. Although most of the fractures of bony
thorax are benign entities and can be followed up without
hospitalization, trauma limited to the thoracic cage itself
may cause profound patho-physiological changes, which
may be lethal if not promptly treated [5].
Penetrating chest trauma is mostly attributed to
violence and has a higher mortality than blunt trauma [6].
It is more common in middle aged and young men than
women and the mechanism of injury is usually a gunshot
or stab wound. We should use ISS for all cases admitted
with trauma to ER. The Injury Severity Score (ISS) is an
anatomical scoring system that provides an overall score
for patients with multiple injuries. Each injury is assigned
an Abbreviated Injury Scale (AIS) score and is allocated
to one of six body regions (Head, Face, Chest, Abdomen,
Extremities (including Pelvis), External). Only the highest
AIS score in each body region is used. The 3 most severely
injured body regions have their score squared and added
together to produce the ISS score.
The ISS score takes values from 0 to 75. If an
injury is assigned an AIS of 6 (unsurvivable injury), the
ISS score is automatically assigned to 75. The ISS score
is virtually the only anatomical scoring system in use and
correlates linearly with mortality, morbidity, hospital stay
and other measures of severity [5, 6].
Patients and Methods
Between February 2013 and September 2015,
1700 patients with chest injury were admitted to the
surgical department of two tertiary centers in Middle East
(in Egypt and Saudi Arabia).  The file records of all patients
were reviewed and data were collected retrospectively.
The demographic features age of the patients, type
of the  trauma,  injury severity score (ISS), clinical
and radiological findings,  associated organ injuries,
management of the pathologies, surgical interventions,
morbidity, and mortality were analyzed.
In the emergency department, the hospital triage
doctor, who is a specialist in emergency medicine or general
surgery, first assessed patients. Priority for admission to
the emergency room and for treatment was determined.
Patients presenting with hypotension, massive blood loss,
or difficulty in breathing were evaluated immediately on
admission. Patients were referred to the thoracic
surgeon as soon as possible whenever needed. The injury
severity score (ISS) was calculated for all patients. All
laboratory investigations were performed including blood
group, CBC, biochemistry, ECG, cardiac enzymes (and
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we are doing ultrasound chest and echocardiography for
all patients have stab wounds on left hemithorax, or right
hemithorax near precordium or in presence of clinical
signs of cardiac injury).
Thoracic pathologies requiring
a chest tube insertion were diagnosed  on physical
examination;  chest X-rays were taken on
admission and CT-thorax imaging was performed in most
of cases. Chest-tube insertion was performed in patients
with pleural complications and in those with massive
subcutaneous emphysema and prominent dyspnea, even if
there was no evidence of pneumothorax in the chest X-ray,
thoracotomy was performed if:
• chest tube output was >1500 ml initially.
• The hourly output was about 200 ml for consecutive
4 hours.
• 500 ml in 2 consecutive hours.
• Stab wound with considerable haemopericardium in
echocardiography.
Patient’s physical condition, number of
fractured ribs, patient’s age, patient’s previous history
of chest disease (especially chronic obstructive pulmonary
disease) and patient’s ISS were among the factors affecting
our decision for hospitalization.
Morbidity  included: wound  infection,
hemoptysis, persistent air leak, pneumonia, atelectasis and
prolonged hospital stay.
Pain management was done effectively using
non-narcotic parenteral analgesics as first line treatment.
The degree of pain relief was assessed by the necessity
of supplementary analgesics according to the capacity of
mobilization, cough and deep inspiratory effort. In the
presence of inadequate pain relief, narcotic analgesics
were used.
Vigorous pulmonary hygiene provided with
aggressive pulmonary  physiotherapy, humidification
of inspired air, encouraged coughing deeply and use
of incentive spirometry. Nasotracheal suctioning or
bronchoscopy was used if necessary to remove retained
secretions and sometimes non-invasive CPAP mask
breathing to expand areas of collapsed lung and to recruit
more collapsed alveoli.
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 Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center Experience. SF J Surgery 1:1.
Results
Of the 1700 patients reviewed, 1564 (92%) were
male and 136 (8%) were female. Ages ranged from 2
years to 78 years, with a mean age of 40 year. Blunt and
penetrating injuries were documented in 1530 (90%) and
170 (10%) patients, respectively (Table 1). Few patients
were identified as having both major blunt and penetrating
injuries (Figure 1, 2, 3). Associated organ injuries were
observed in 664 cases (39%). Traffic accidents were the
leading cause of blunt injury, while stab wounds were
the most common type of injury in penetrating trauma,
gunshot patients only in 12 patients. Mean ISS was
19±7.4 in blunt, 20.7±2.9 in penetrating, and 22.0±5.5
in associated organ injuries. The mean hospital stay of
was 9.2 days, ranged from 1 day to 24 days; 11.7 days in
blunt, 8.2 days in penetrating, and 16.3 days in associated
Figure 2 (a, b, c, d): Penetrating chest wall injury, which was diagnosed only with CT chest despite it, was not clear in gross examination and CXR
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injury. Chest wall pathologies presented in 60% of cases
in this series. Rib fractures were diagnosed in 914 patients,
of which 714 (78.12%) had one or two rib fractures and
200 (22.188%) had more than two rib fractures. Clavicle
and sternal fractures were 70 and 36 patients respectively.
Pleural complications were noted in 1224 patients (72%).
Pulmonary contusion and laceration were diagnosed in
208 and 36 patients respectively. Flail chest was diagnosed
in 28 patients (1.6%), and most of them were followed in
the intermediate care unit (IMCU); surgical fixation was
not applied. 12 cases with diaphragm ruptures (0.8%) were
discovered either at the time of admission to the hospital or
second or third day of admission. Repair of the diaphragm
was performed via thoracotomy, while patients repaired
via laparotomy were excluded. All types of isolated chest
injuries were documented (Table 2, 4).
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 Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center Experience. SF J Surgery 1:1.

Figure 3: a) CT chest showing massive bilateral chest wall emphysema, lung contusions and rib fractures after Road traffic accident. b) CXR after
chest tubes insertion

Additional extra-thoracic organ’s injuries were
documented, including head injuries, abdominal, aortic,
bony and spinal injuries (Table 3).
Tube thoracostomy was performed in 1402
patients (82.5%).
Thoracotomy was performed in 156 cases
(9%) (Table 4). The most common indication for early
thoracotomy was significant intrathoracic hemorrhage.
The overall morbidity rate in the management
of chest trauma in our series was 22.2% including lung
atelectasis, prolonged mechanical ventilation and chronic
empyema. Atelectasis was the most common morbidity,
with an incidence of 14.6% in all cases. On the other hand,
An example of the ISS calculation is shown below:
in associated injuries, adult respiratory distress syndrome
(ARDS) developed in 3.3% of patients as a secondary
morbidity after atelectasis. Only 36 cases (2.8%) were
followed-up in the ICU, and 20 (1.2%) needed mechanical
ventilation.
In this series, mortality rate was 34 patients
(2.1%).
All mortality patients were in blunt trauma with
associated injuries particularly those with associated
severe head trauma with Glasgow Coma Scale GCS less
than five and those with severe extremity injuries.

Region Injury Description AIS Square Top Three

Head & Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Minor Contusion of Liver 2  -
Abdomen
Complex Rupture Spleen 5 25
Extremity Fractured femur 3
External No Injury 0
Injury Severity
50
Score:

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 Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center Experience. SF J Surgery 1:1.

Table 1: Mechanism of chest injury in 1700 patients

Mechanism of Injury No. of Patients

Blunt injuries 1530 (90%)
Penetrating injuries 170 (10%)

Table 2: Isolated chest injuries

Type of chest injury Number of patients

Isolated chest Injury 1020(60%)
1-2 Rib fractures only 714
More than 2 Ribs fractures (Non-flail) 200
Flail chest 28
Clavicle fracture 70
Sternum fracture 36
244
Parenchymal lung injury Lung contusion 208
Lung lacerations 36
Diaphragmatic rupture 12

NB: isolated chest injuries are one or combination of the above

Table 3: Additional extra-thoracic injuries

Additional Injury No. of patients

Bone fractures 612 (36%)
Abdominal injury 136 (8%)
Head injury 188 (11%)
Spinal trauma 22(1.3% )
Aortic injury 4 (0.24%)

Table 4: Indications for open thoracotomy

Variable Number of patients

Open thoracotomy 156 (9%)
Indication for thoracotomy:-
Massive persistent air leak 26 (1.5%)
Massive hemothorax 100 (5.9%)
Diaphragmatic injury 12 (0.7%)
Cardiac tamponed 12 (0.7%)
Others (as retrieval of intrathoracic foreign body & chest wall loss … etc.) 6 (0.4%)

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 Citation: Mohamed Alassal (2017) Chest Trauma: A Tertiary Center Experience. SF J Surgery 1:1.
Discussion
Thoracic trauma is still a major cause of
hospitalization in developing countries. Although the
number and figures may change according to the social
and economical conditions of the population as well as the
location of the hospital, our hospitals receiving the higher
percentage of trauma patients through the Red Crescent
account for about 400 patients per month blunt traumas are
generally much more frequent than penetrating traumas. In
our series of 1700 patients, 90% of the victims had a blunt
chest injury. In particular, high-speed vehicle accident
were the main cause of blunt thoracic trauma similar
to other studies [3, 4, 7, 8]. Our series did not confirm
gunshots as the most common cause for penetrating
injuries which occurred only in 12 patients, as has been
previously reported to account for 60% of penetrating
injuries in other studies. [9, 10] Other studies reported
higher percentage of penetrating than our study, in two
studies it’s reported to be 28% and 20% [11, 12]. In chest
trauma, associated extrathoracic injuries complicate the
presentation and management of the victims, resulting
in increased mortality and hospital stay [13]. The ratio
of associated injuries was higher in our study than the
other literature (42%), we experienced that mortality
and hospital stay increased when compared to isolated
thoracic injuries. In our series, the incidence of chest wall
pathologies was 60%, of which rib fractures in 92.4%, this
percentage was higher than that reported in other literature
[14]. Although the number of fractured ribs may indicate
the severity of the injury, some authors believe that, it has
no significant relation with morbidities [2, 15]. However, in
our experience, 10.9% of patients had fractures involving
more than three ribs. We observed that the morbidity rate
and hospital stay were both increased in these patients, 28
patients suffered from flail chest resulted in paradoxical
movement which caused respiratory insufficiency and the
need for special care. Some authors recommend surgical
stabilization of the chest wall only during thoracotomy but
others recommend early fixation on diagnosis to decrease
morbidity and mortality [13, 16], we didn’t apply surgical
stabilization for any of our patients and only 10 of them
required mechanical ventilation.
Though some patients immediately die after
diaphragmatic injury, its incidence in penetrating and blunt
injury has been reported as 3.4 and 2.1%, respectively in
one study [17]. In this series, we had 12 patients with
diaphragmatic injury, which all resulted from blunt chest
trauma. In cases of diaphragmatic injury, the choice of
surgical approach depends greatly on associated injuries;
SF J Surgery
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we repaired all via early thoracotomy, whereas 8 patients
underwent a late thoracotomy within three days, and
patients with diaphragmatic injury repaired by laparotomy
was excluded in this study.
We observed that blunt chest trauma frequently
caused smaller tears in the airways, leading varying degree
of pneumothorax and/or subcutaneous (SC) emphysema,
in many of these cases it’s suspected that tracheal injury
during endotracheal intubation was the cause of SC
emphysema. Patients presenting with larger tears that
had resulted from penetrating trauma were rare; we did
not encounter any patient with large tracheobronchial tear
needs surgical repair. In the literature, tracheobronchial
rupture has been reported in 1-2% of cases with blunt
chest injury [2, 15]. Tube thoracostomy is the choice of
treatment in chest trauma complicated with hemothorax,
pneumothorax and hemopneumothorax. In our series, tube
thoracostomy was performed in 1402 patients (82.2%)
with favorable outcomes. However, 154 patients with
chest tube drainage underwent an early operation due to
bleeding. On the other hand, the ratio of thoracotomy in
this study was 9%, which is higher than other studies [17,
18]. Intrathoracic bleeding was the leading pathology in
most of patients.
The mortality rate for isolated chest injuries has
been reported to range from 4 to 8%; this value increases
to 13-15% when another organ system is involved and to
30-35% when more than one organ system is involved [19,
20]. In our series, overall mortality rate was 2.1% in chest
injury patients, it was higher in blunt chest injury. Blunt
chest trauma usually caused by motor vehicle accidents
and falls, middle aged group had the highest incidence
of blunt chest trauma and mortality, this encourages us
to raise community education about its hazards as well as
application of tough regulations for traffics and violence.
We observed that associated extra-thoracic injuries
caused a higher mortality rate. Thus, clinicians should have
a high index of suspicion for associated pathologies after
an injury. An understanding of the modes of presentation
allows prompt diagnosis and early treatment, making
management more efficient.
Conclusion
Multidisciplinary approach in the management of
trauma cases is life saving and decreases morbidity and
mortality. Mortality in chest injury could be significantly
reduced if traffic accidents, violent activity, and social
problems solved.
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