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Surgeon General Vol. 31 No. 1 - 2009

 
ORIGINAL ARTICLE

Penetrating trauma to the abdomen and thorax: Study

of cases in the General Hospital of Ciudad Juárez
Penetrating trauma in the abdomen and thorax: case studies at the General
Hospital in Ciudad Juarez, Mexico

Dr. Juan de Dios Díaz-Rosales, Dr. Lenin Enríquez-Domínguez, Dr. Jesús Manuel Arriaga-Carrera, Dr.
Pedro G. Gutierrez-Ramirez

Summary Abstract
Objective: To know the epidemiological characteristics Objective: To know the epidemiological character-
cases of penetrating trauma to the chest and abdomen istics of penetrating trauma in the thorax and abdomen
in Ciudad Juarez. men in Ciudad Juarez, Chihuahua, Mexico.
Design: Descriptive study; cross. Design: Descriptive, transversal study.
Setting: General Hospital of Ciudad Juárez (Hospital Setting: General Hospital of Ciudad Juarez (Second
second level care). level health care hospital).
Statistical analysis: Percentages as a measure of Statistical analysis: Percentages as summary mea-
summary for qualitative variables. sure for qualitative variables.
Patients and methods: Trauma patients Patients and methods: Patients with penetrating trauma
penetrating chest and abdomen. Study variables ma of the thorax and abdomen. studied variables
das: gender, origin, age, schooling, social level were: gender, origin, age, schooling, socioeconomic
socioeconomic, occupation, day of the week and time level, occupation, day of week and time at which
in which the incident occurred, presence and type of the incident occurred, presence and type of intoxica-
alcohol and/or drug intoxication, type of injury, cation, alcohol and/or drugs, type of injury, mecha-
mechanism of injury, time between injury and hospital nism of injury, time elapsed between the injury and
talization, anatomical site of trauma, reason for hospitalization, anatomic site of the trauma, rea-
discharge, and prehospital care. are for discharge, and prehospitalization care.
Results: 104 patients were included, 101 male- Results: Hundred-four patients were included in the
men and 3 women, 77.9% from Ciudad Juárez, study; 101 men and 3 women; 77% were born in
mean age 29.1 years (14-60), median 27. Juarez City; average age of 29.1 years (range, 14
Truncated or completed primary schooling 57.7%, se- to 60), mean of 27. Grade school, incomplete or fin-
truncated or completed secondary school 30.7%, socioeconomic
ished, 57.7%;
level junior-high school incomplete or fin-
economic low 78.8%, permanent employment 38.46%, employment
ished, 30.7%; low socioeconomic level, 78.8%; fixed
temporary 30.77%, unemployed 20.19%, active employment, 38.46%; temporary employment,
ties related to drug trafficking 5.7%, students 30.77%; unemployed, 20.19%; drug traffic-related
teas 2.88% and housewives 1.92%. 55.7% of the activities, 5.7%; students, 2.88%; and housewives,
injuries occurred on Saturday and Sunday 1.92%; 55.7% of the injuries occurred on Saturdays
Friday guidos with 12.5%. Hour of injury, 16.3% and Sundays followed by Fridays with 12.5%. Time
at 03:00 a.m.; 14.42% at 11:00 p.m.; 12.50% at of injury: 16.3% at 03:00, 14.42% at 23:00, 12.50%
02:00 a.m.; and 12.50% at 01:00 a.m.; 72.1% were related at 02:00 a.m., and 12.50% at 01:00 a.m.; 72.1% were relative
tioned with some state of intoxication; 62.5% ed with intoxication; 62.5% were cared for during
attended in the first hour and 26.9% in the second. the first hour and 26.9% on the second hour post-
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  Surgery Service of the General Hospital of Ciudad Juárez
Postgraduate Division/Medical Specialty of General Surgery/Autonomous University of Ciudad Juárez
Received for publication: November 25, 2008
Accepted for publication: December 20, 2008
Correspondence: Dr. Juan de Dios Díaz-Rosales
Av. Paseo Triunfo de la República, No. 2401 Oriente, Col. Margaritas. Ciudad Juarez, Chih., Mexico, 32200. Tel. (+656) 617 13 23
Cell. (+656) 319 81 52
Email: juandedios@salud.gob.mx

Volume 31, No. 1 January-March 2009 9

Dr. Diaz-Rosales
 
second hour post-injury. 60% had prior assistance injury. Prehospital care was given to 60%; 56.73%
hospitable. 56.73% suffered gunshot wounds. suffered gunshot injuries and 43.27% were caused
fire and 43.27% by knife or pointed object. by cutting weapons; 44.2% in the abdomen, 38.4%
cutting; 44.2% in the abdomen, 38.4% in the chest and 17.3%
in the thorax, and 17.3% in both, thorax and abdo-
in chest/abdomen. 69.23% was due to fights men. Street fights correspond to 69.23%; 94.23%
llejeras 94.23% were discharged due to improvement, 3.85% weredied.
discharged after improving; 3.85% died, and
ron and 1.92% were transferred to another hospital. 1.92% were transferred to another hospital.
Conclusion: The highest frequency of penetrating injuries Conclusion: The highest frequency of penetrating
Abdominal and thorax tracing in Ciudad Juárez is given trauma to the abdomen and thorax in Cd. Juárez
in 27-year-old men with low educational level occurs in 27-year-old men, of low educational lev-
tional, with alcohol intoxication and/or drugs during el, under the effects of alcohol or drugs during street
you get into street fights between 11:00 p.m. and 3:00 a.m.fights between 23:00 and 03:00 h from Fridays to
on Friday to Sunday. The occupation does not Sundays. Occupation has no relation with the fre-
relationship with the frequency of injury. 40% of the quency of injuries; 40% did not receive pre-hospital
injured did not receive prehospital care. such care.

 Keywords: Thoracic trauma, abdominal trauma,  Keywords: Thoracic trauma, abdominal trauma, pen-
penetrating trauma, firearms, statistics. treating trauma, gunshot, statistics.
Cir Gen 2009;31:9-13 Cir Gen 2009;31:9-13
   

Introduction mities, who enter the service as a first option

Ciudad Juárez is one of the most hospital tion. Excluded are patients with
between Mexico and the United States, with a penetrating wounds to parts other than the thorax and
population of 1,313,338 inhabitants, which places it as abdomen, those that do include thorax and abdomen but
the most populous city in the state of Chihuahua and the who are referred from other hospital stays with
seventh largest city in the country. 1 Course with a established treatment. The study variables are:
i i i hi h i i i i d i i h li i i l l
constant immigration, which, in turn, registers an intention gender, origin, age, schooling, socioeconomic level
so commercial, social and cultural exchange. This city- co, occupation, day of the week and time it occurred
ity faces serious problems generated by the con- the incident; if the patient came in a state of intoxication
conditions of backwardness and marginalization of a large alcohol
part of and/or drug use, type of narcotics used
the population. It is considered one of the cities lysed, type of injury, mechanism of injury, time
most insecure in the country, with an index of external violence
between injury and hospitalization, anatomical site of trauma
alarming tremor leading to homicides and injuries reason for discharge, and if you received extra-hos-
that endanger life. Almost all of the pitalaria. The data was analyzed by means of
population is entitled to Seguro Popular; the percentages as a summary measure for variables
sector called Open Population, which is attacked, quantitative.
is referred and treated at the Emergency Service of the
General Hospital of Ciudad Juarez; cases with trauma Results
Penetrating injuries from a firearm projectile The results in six months of study (April to September)
or sharp objects in the chest and abdomen are de- December 2008) are as follows: A total of
referred to the General Surgery Service, which is total of 104 patients with penetrating trauma in
burden of their assessment and treatment, as well as their thorax and/or abdomen, 101 cases belong to the sex
follow-up. male (97.1%) and 3 female (2.9%) with
This study aims to describe the characteristics a ratio of 33.6:1 respectively. eighty and
Epidemiological characteristics of penetrating chest traumaone patient was from Ciudad Juárez (77.9%),
rax and abdomen in the Surgery Service of the Hospital while 22 were from the rest of the Republic (21.2%)
General of Ciudad Juarez. and one US citizen (0.9%).

Patients and methods www.medigraphic.com

The age range oscillated between 14 years as a minimum
and 60 as maximum, with an average age of 29.1
The study was carried out by the Department of Surgery in years old, with a median age of 27. The group
the General Hospital of Ciudad Juárez, in a period of The most affected group with respect to age was 15-
6 months, where the data of the patients were collected. 20 years in 24.04% (n = 25), followed by the range of
patients with penetrating trauma to the abdomen and chest21-25 with 21.15% (n = 22). Figure 1 shows
admitted to the General Surgery Service for evaluation behavior according to age range, number of parents
ration and treatment. All patients included cients and their percentages.
with penetrating trauma to the chest and abdomen, with Patients according to level of schooling were distributed
independence of injuries to the face, neck, and/or extremities
were illiterate in 1.9% (n = 2), with prima-

10 General Surgeon

Penetrating trauma to the chest and abdomen

 
truncated or terminated ria 57.7% (n = 60), with secondary (n = 58) of the cases, followed by Friday with
truncated or finished 30.7% (n = 32), with high school or 12.50% (n = 13) of the cases.
equivalent 9.6% (n = 10). According to socioeconomic level According to the time of the incident: 17 patients (16.35%)
nomic, 78.85% had a low level (n = 82), 18.27% were injured during 03:00 h, 15 (14.42%)
had medium level (n = 19) and 2.88% had high level during 23:00 h, 13 (12.50%) during 02:00 h and
(n = 3). According to occupation, 38.46% (n = 40) of the pa- 13 (12.50%) at 01:00, 9 (8.65%) at 00:00
patients had a permanent job, 30.77% (n = 32) with h; 25% (n = 26) of the patients came with intoxication
casual employment, 20.19% (n = 21) were unemployed, alcohol consumption, 4.8% (n = 5) intoxicated with single drugs
5.77% (n = 6) had activities related to the mind, and 42.3% (n = 44) patients with intoxication
drug trafficking, 2.88% (n = 3) were students and 1.92% for drugs and alcohol at the same time, while
(n = 2) were dedicated to the home as housewives. 27.9% (n = 29) of the patients did not present intoxication
Injuries by days of the week were distributed any cation. Thus, in 72.1% (n = 75) of the patients
as shown in figure 2, observing greater tes, the incident was related to some state
incidence between Saturday and Sunday with 55.76% of intoxication. Among the most used drugs were

30
  
24.04%
25
    21.15%

s twenty
and
 
you
n
iand
  17.31%
c  
to
p
andfifteen
d   12.50%
ror
and
m  
or 10 8.65%
N
  7.69%
 
  4.81%
5
  0.96% 2.88%   Fig. 1. Incidence observed
eleven 25 25 22 22 18 18 13 13 9 9 3 3 8 8   55 by age group, the four
0   they were divided every 5
    21-25 26-30
<15 15-20     36-40 41-45
31-35   46-50 51 or >         years. The number is observed
of patients and their distribution
Age ranges in years percentage.

35
  
27.88% 27.88%
30
 
   
s 25
and
you  
n
iand
c twenty
to
p  
and
d 12.50%
or fifteen
r
and
m
or
 
8.65%
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8.65% 7.69%  
N 10
6.73%
 
     
5  
 
29 29 9 9 8 8 77 13 13 9 9 29 29
0
  Sunday Monday Tuesday Wednesday Thursday Friday Saturday Fig. 2. Shows the casuistry
by number and percentage,
Weekdays depending on the days of the week.

Volume 31, No. 1 January-March 2009 eleven

 Dr. Diaz-Rosales

 
rum: cocaine in 23.08% (n = 24), heroin in 14.42%
(n = 15), marijuana in 13.46% (n = 14), 7 patients
 
(6.7%) combined two or more types of drugs.
Period between injury and hospitalization: 65 patients
(62.5%) attended the hospital during the first hour
after the injury, 28 during the second (26.92%), 4 18; 17.31% 18; 17.31%
during the third (3.85%) and 7 in the following hours  
(6.73%), up to a maximum of 12 hours secondary to
the injury. In 60% (n = 62) of the cases, they were granted
aid for paramedical services, providing assistance
prehospital care; while 40% (n = 42) 46; 44.23% 46; 44.23%

 
went to the hospital by his own means (private car)  

 
lar, taxi, collective transport, walking, etc.).
According to the mechanism of injury, 59 patients 40; 38.46% 40; 38.46%
(56.73%) suffered injuries from a projectile fired by
firearm (HPAF) and 45 patients (43.27%) with
Stab or sharp object injuries
(HPAB). Depending on the site of injury, in the abdomen,
They found 46 cases (44.23%), while in the chest 40
cases (38.46%), and finally in the chest/abdomen 18
cases (17.31%) (Figure 3).
Of the patients with HPAB, 15 were in the chest
(14.42%), 22 in the abdomen (21.15%) and 8 with injury to
chest and abdomen (7.69%). In regards to the   Abdomen   Chest   Chest/Abdomen
HPAF, 25 patients had chest involvement
Fig. 3. The frequency of the lesion site is observed, with greater
(24.04%), 24 patients with abdominal injury (23.08%) incidence in the abdomen, followed by the thorax and finally the bino-
and 10 patients with thoracoabdominal involvement (9.62%)myothorax-abdomen, which was affected to a lesser extent.
(Figure 4).
According to the cause of the injury, 69.23% (n = 72) were due
were involved in street fights, 15.38% (n = 16) were injured when
30
try to rob other people or establishments,   
7.69% (n = 8) were assaulted during an assault, 5.77% 24.04% 23.08%
25
(n = 6) had activity-related injuries   21.15%
with drug trafficking, 1.92% (n = 2) were fatal injuries.    
(stray bullets in a confrontation between groups) twenty  
 
post armed). Discharges were 98 (94.23%) due to 14.42%
improvement, 4 (3.85%) due to death and 2 (1.92%) due to fifteen    
next to another hospital unit. 9.62%
10 7.69%
     
Discussion  
5
According to the results, the masculine gender is preponderant
in the incidence of penetrating injuries
  22 22 15 15 25 25 24 24 8 8 10 10
in the thorax and abdomen, with an incidence of 33.1 0
men for every woman affected in Ciudad Juárez,
  Chest   Abdomen   A/T  
similar to what was observed in other national series HPAB HPAF
them.2,3,5 As expected, most of those affected    
Fig. 4. A comparison between HPAB and HPAF is observed
respondents were originally from Cd. Juárez (77.9%), however
according to site of injury in number of cases and percentage.
However, it should be noted that the huge population
immigrant is increasingly affected; in this series
reached 22.1%, which will be compared with studies
later.
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It was found that the highest incidence lies in the
On the other hand, it was also observed that the degree of
study is inversely proportional to the risk of su-
age group from 15 to 35 years (78%), observing- fries this type of lesions (patients affected with
I know that youth is always a risk factor in primary studies occupied 57.7% of the population
the penetrating traumas of this casuistry. I know understood, decreasing the incidence according to the degree
should consider penetrating trauma as a do of later studies). The socioeconomic level is
of the main conditions in patients younger than also a very important factor, since up to a
40 years, a very important fact because this group 78.8% of the patients in this study belong to the
includes economically active people with low socioeconomic stratum, converting this variation
longer life expectancy. 2,5,6
ble in a factor that must be taken into account.

12 General Surgeon

Penetrating trauma to the chest and abdomen

 
The type of occupation seems to have no significance, trafficking, use and abuse of drugs among others, as
4
since the incidence of patients with permanent employment, confirmed in our study. Cristiani-Diaz and Beltran
casual and unemployed is not considered significant consider that this pathology already constitutes a problem
goes, 38%, 31% and 20%, respectively. It is worth highlightingof public health that requires medical services
note that six patients had activities related to hospitals a correct systematization of care
You openly deal with drug trafficking. patients injured by gunshot wounds
Both Saturdays and Sundays were the fire, as well as proper training for surgeons.
days with the highest incidence, while in the rest of janos who treat this pathology. 8

days a similar incident occurred. So too Our group offers this article with epidemiological data
establishes a critical or risk schedule, which is local myological and statistical studies, in one of the cities
It is between 11:00 p.m. and 3:00 a.m., which was when who suffer most from this phenomenon, giving us
64.4% of the cases occurred. foot to the continuous search for Mexican statistics
It was observed that the alteration in the state of con- in this area, a situation that should become a
science, caused by intoxication with ethanol or drugs
THIS DOCUMENT IS PREPARED BY MEDIGRA-
institutional habit 9.10, in order to improve the quality
illicit
PHIC
gas, favored and predominated in the previous cases of the services provided.
seated, up to 72.1%, higher than in other series Therefore, we can conclude that the highest frequency
nationals. 7 Being already established the binomial intoxication
Penetrating injuries to the abdomen and chest in Cd.
cation-penetrating injury, demonstrated once again in Juárez occurs in 27-year-old males with low
this casuistry, with alcohol intoxication being the form educational level, with alcohol intoxication and/or drugs
most common, followed by the drug-alcohol binomial. Fromgas during street fights between 23:00 and 03:00
Among the narcotic drugs, cocaine was the most used. hours from Friday to Sunday. occupation not
zed, followed by heroin and marijuana, unlike is related to the frequency of injury. 40% of
difference from other series where inhalants were the mostThe injured did not receive pre-hospital care.
used. 7 It was observed that the majority of patients
(87.5%) attend within the first 2 h after the
incident; This obviously translates into a better pro- References
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Of the 104 patients treated, 59 patients suffered Second Population and Housing Count 2005. http://
45 with HPAF (56.7%) and 45 with HPAB (43.3%), observing
with a slight predominance by the HPAF, figures that di-
differ from other studies of Mexican statistics,
where a higher HPAB incidence is observed. 7 the site
“preferred” lesion was the abdomen, followed by the thorax
and finally thorax-abdomen injury. in the HPABs
a predominance of lesions in the abdomen is observed,
while in injuries due to fired projectile
per firearm, there is a number practically
as well as injuries to the chest and abdomen. This leaves in
It is clear that the type of violence that Ciudad Juá-
rez is even more extreme than in the rest of the Republic.
Mexican ca.
Most of the injuries (84.61%) were occasional
swimming during acts of vandalism (fights and assaults),
making it clear that this type of "modus vivendi" is
a high risk factor for the incidence of this fe-
nomenus It should be noted that six injured had
activities related to drug trafficking
Frankish manner, of whom four died during the
intraoperative or postoperative. Finally, 94% of
www.medigraphic.com
the patients were discharged due to improvement.
Sotelo-Cruz et al. 3 ratified that the HPPAF in
children and young people are a problem in which they interrelateRM. Experience in spleen trauma in rural hospitals.
mention family disintegration, social maladjustment,
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www.inegi.gob.mx
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13