International Journal of Surgery Open 37 (2021) 100420

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International Journal of Surgery Open

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Mortality rate and factors associated with death in traumatic chest injury
patients: A retrospective study
Abubeker Eshetu Yimam a, Salh Yalew Mustofa b, *, Amare H/kiros Gebregzi b, Habtu Adane Aytolign b
a
Department of Anesthesia, School of Medicine,College of Medicine and Health Sciences, Debretabor University, Ethiopia
b
Department of Anesthesia, School of Medicine,College of Medicine and Health Sciences, University of Gondar,Gondar, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Traumatic chest injury is responsible for 10%e15% of all trauma-related hospital admissions
Received 11 August 2021 across the world. It is also responsible for approximately 25% of trauma related death. Several predictors
Received in revised form have been described for mortality following chest trauma however, limited published studies were
2 September 2021
available in Ethiopia.
Accepted 6 September 2021
Available online 4 October 2021
Objective: To assess mortality rate and factors associated with death in traumatic chest injury patients
over five year's period from June 2016 to June 30, 2020 G.C.
Method: A retrospective cross-sectional study was done from June 2016 to June 30, 2020. Data was
Keywords:
Chest injury
collected from patients’ chart. The collected data was entered into Epi-info version 7 and transferred to
Mortality SPSS version 20.0 for processing and analysis. Bivariable and multivariable logistic regression was used to
Factors show factors associated with mortality. P- Value < 0.05 was considered statistically significant.
Trauma severity Result: A total of 419 patient charts were eligible for this study. The majority of patients (55.8%) sustained
blunt chest injuries and violence (52.5%) was the leading cause of injuries. Hemopneumothorax (27.7.0%),
hemothorax (22.9%) and rib fracture (17.2%% were the most common type of injuries. Associated extra-
thoracic injuries were noted in 70.4% of patients, from those, extremity injury (22.2%), head/neck injuries
(21.7%) and abdominal injuries (18.1%) were the commonest. Most patients (64.7%) were treated suc-
cessfully with chest tube. Nearly, one third (35.3%) had complications including pneumonia (13.8%) and
Atelectasis (12.6%). The mean length of hospital stay was 9.40 days. The overall traumatic chest injury
mortality rate was 26%. Mortality was significantly associated with age >50 year [AOR 9.32, 95% CI, 2.72
e31.86], late presentation beyond 6hr (AOR 7.17, 95% CI 1.76e29.21), bilateral chest injury (AOR 3.58 95%
CI 1.53e8.38), penetrating chest injury (AOR 3.63 95% CI 1.65e7.98), presence of extra-thoracic injury
(AOR 4.80, 95% CI, 1.47e15.72) and need for mechanical ventilation (AOR 11.18, 95% CI 2.11e59.23).
Conclusion: The mortality rate in traumatic chest injury was high. Late presentation beyond 6hr, age
>50-year, penetrating injury, bilateral chest injury, associated extra thoracic injury, and need for me-
chanical ventilation were identified as possible risk factors for mortality in traumatic chest injury
patients.
© 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

1. Introduction 1.3 million, suicides 844,000, and homicides 600,000 deaths per year.
Even though, about 91% occur in developing countries, it is still major
Traumatic damage is the principal cause of death and disability public health problem in both high and low incomes countries.
worldwide. It happened frequently in first four decades of life. Glob- Trauma negatively affects the health of population regardless of age,
ally 5.8 million people die every year from non-intentional traumatic sex, religion, income and residency[1e3].
injuries and violence. Road traffic accidents were responsible for up to It is also a continuing challenge in Ethiopia, as the magnitude of
injury was seen in Tikur Anbesa Hospital (32%), Dilla University
Hospital (46.6%), in the whole Amhara Regional State (55.6%) and in
* Corresponding author.
one Amhara Regional State hospital (25%). This exposed to a sig-
E-mail addresses: abueshetu90@gmail.com (A.E. Yimam), salihyalew11@gmail. nificant economic and social crisis more than 10% of all disease
com, salihyalew11@gmail.com (S.Y. Mustofa), amaretom22@gmail.com cases[4e8].
(A.H.–g.–> Gebregzi), habituadane@gmail.com (H.A. Aytolign).

https://doi.org/10.1016/j.ijso.2021.100420
2405-8572/© 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Globally Chest trauma is responsible in a rate of 10e15% of all
traumas related hospital admission. It directly responsible for
approximately 25% of trauma related death. Death caused by
traumatic chest injury ranked in third place after head and spinal
cord injuries. Since the chest is a large and exposed area, it is high
likely susceptible for impacted injuries. Even though thoracic cage
is a protective of vital organs like heart, lungs and great vessels
injury to these organs can prove fatal. Moreover, delayed in inter-
vention and late diagnosis has significant mortality[3,9e12].
Chest trauma is causing a variety of injuries, ranging from
simple abrasions and contusions to life-threatening insults. Life
threatening conditions explained by the complexity of thoracic
injuries and related respiratory failure. Trauma to chest results a
significant morbidity and mortality in developing countries.
Growing of urbanization and creation of high-speed motor vehicles
has resulted in enormous increase in the number of traumatic chest
injuries[9,12,13].
Chest injury is a powerful indicator of pulmonary deterioration
and complications. The risk of complication is greatest in older
population with increased ventilator days, pneumonia and acute
respiratory distress syndrome when compared with younger ages.
Another mark of severity of chest trauma is bilateral chest
involvement. So, nearly 50% of mortality occurred among the pa-
tients who suffered bilateral chest involvement[14e16].
Both blunt and penetrating chest trauma can result mortality.
Even though, in most series blunt chest trauma occurs more
frequently than penetrating chest trauma. Most of the time blunt
chest trauma will be caused by motor vehicle accident, fall down
and crush injuries. While penetrating chest trauma can be caused
by gunshot, stab and blast injuries[14,17].
The pattern and causes of chest injuries reported in literatures
may vary from one country to another part of the world because of
variations in infrastructure, civil violence, war, crime and applica-
bility of traffic rules and regulations[18].
In Ethiopia, trauma is still public health problem. For instance,
death rate in emergency department from traumatic chest injury
was 30.1% at Tikur Anbessa Specialized Teaching Hospital. Another
study in this Hospital on road traffic related chest injury accounts
13.9%. Additionally, chest injury caused by RTA responsible 9.5% at
Zewditu Memorial Hospital and 9.7% Ayder Referral Teaching
Hospital[19e22].
Fortunately, majority of patients managed in the form of chest
physiotherapy, analgesia, antibiotics and by closed tube thor-
acostomy procedure. However, a few requiring thoracotomies
(7e20%). Tube thoracostomy is frequently used in thoracic trauma
patients. It is required in case of pleural disruption caused by
hemothorax, pneumothorax or hemopneumothorax. In life-
threatening conditions diagnosis and prompt treatment should
be started simultaneously. Airway, breathing, circulation (ABC)
management approach is crucial. Patients with minimal pneumo-
thorax and minimal hemothorax underwent thoracentesis alone.
Indeed, some patients are still requiring thoracotomy. Complica-
tions like pneumonia, wound sepsis, and atelectasis are common
[9,23e25].
2. Methods and materials
After ethical clearance was obtained from the institution ethical
review committee, a retrospective cross-sectional study was con-
ducted. Patients diagnosed clinically or imaging or both and those
received treatment for traumatic chest injury for the last five years
period from June 2016 to June 30, 2020G.C. were enrolled in the
study. Data was collected by using patient chart review. The list of
patients diagnosed with traumatic chest injury was identified from
patient registry of the hospital emergency department. Then, the
records of each patient were accessed from record office based on
the identified list. Finally, it was evaluated and reviewed manually
for its eligibility to meet the required inclusion criteria. This study
registered at http://www.researchregistry.com Research Registry
UIN: researchregistry7105 and reported according to STROCSS
criteria [41].
2.1. Inclusion criteria
All patients diagnosed clinically and/or imaging for chest injury
and received treatment from June 2016 to June 30, 2020G.C. were
included.
2.2. Exclusion criteria
Missed or incomplete chart documents, patients who died
immediately at the time of their arrival to the hospital before
receiving healthcare and those referred to other centers after
admission were excluded.
2.3. Dependent variables
Mortality rate.
2.3.1. Independent variables
Socio demographic factors (Age, sex), time of arrival, systolic
blood pressure on arrival, chronic medical illness, mechanism of
injury, types of chest injury, associated injury, treatment modal-
ities, severity of chest injury, the need for ICU admission, the need

Table: 1
Basic characteristics of study participant from June 2016 to June 30, 2020 G.C.

Status Category N (%) Outcomes X2

Death Recovered

Sex Male 321 (76.6) 84 237 .897

Female 98 (23.4) 25 73
Age (years) <20 63 (15) 10 53 . .002
21e35 185 (44.2) 38 147
36e50 95 (22.7) 33 62
>50 76 (18.1) 28 48
Blood Pressure (mmHg) <90 55 (12.4) 23 29 .001

90 367 (87.6) 86 281
GCS on admission 3e8 36 (8.6) 23 13 .000
9e12 32 (7.6) 15 17
13e15 351 (83.8) 71 280
Presence of chronic comorbidity Yes 112 (26.7) 37 75 .048
No 307 (73.3) 72 235
Length of Hospital stay (days) Mean ± Sd ¼ 9.40 ± 3.879

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A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

patients were males. Males to females’ ratio were 3:1. The majority
192 (45.8%) of chest trauma patients admitted to health care fa-
cilities within 2e6 h after injury occurred while 174 (41.5%) of them
admitted after 6 h (Fig. 1). Upon hospital arrival 55 (12.4%) of pa-
tients had systolic blood pressure less than 90 mmHg. Thirty-six
(8.6%) of patients had Glasco comatose scale of 3e8 on admis-
sion. Nearly one-fourth (112, 26.7%) patients were with history of
underlying chronic comorbidities of which cardiovascular disease
were the commonest disease 50 (11.9%). The average length of
hospital stay was 9.40 ± 3.879 days (Table 1).

3.2. Pattern and mechanism of injury

Fig. 1. Time spent between injury and admission from June 2016 to June 30, 2020 G.C.

Violence was the most common mechanism of traumatic chest

injury followed by, road traffic collision which accounts for 220
for mechanical ventilation, presence of blood transfusion and
(52.5%) and 120 (28.6%) cases respectively. The majority 234 (55.8)
presence of complications.
of patients had blunt chest injury while 185 (44.2%) had pene-
trating chest trauma. The ratio of blunt trauma to penetrating
2.4. Data processing and analysis
trauma was 1.3:1. Nearly, three fourth (311, 74.2%) of the victims
were admitted with isolated chest injury whereas the rest of the
The collected data was checked manually for completeness.
victims had sustained thoracoabdominal injuries. The majority of
After cleaning and coding it was also entered into Epi-info-7 then
victims had unilateral injurie 357 (85.2%) whereas 14.8% of the
exported to Statistical Package for the Social Sciences (SPSS) version
patients had chest trauma involving both sides of the chest. During
20.0 windows for analysis. Chi-square test was used to test for
admission, among traumatic chest injured patients 291 (70.4%) had
significance of associations between the predictor and outcome
associated extra-thoracic injuries. The commonest were extrem-
variables in the categorical variables. Any variables that were sig-
ities (22.2%), head (21.7%) and abdominal injuries (18.1%) (Table 2).
nificant at P  0.2 in the bivariable analysis were candidate for entry
The most frequent type of chest injury was hemopneumothorax
into the multivariable analysis. The strength of the association
(116, 27.7%) followed by hemothorax (96, 22.9%) and rib fracture 72
presented by adjusted odds ratio and 95% Confidence interval. P-
(17.2%) (Table 3).
value less than 0.05 were considered as statistically significant.
Finally, data was presented by using numbers, frequencies, tables
and figures. 3.3. Management

3. Results As regards to the various treatment options for chest injuries, 76

3.1. Basic characteristics of chest trauma patient
A total of 419 traumatized chest injury patient charts were
reviewed. The mean ± SD of patients' age were (36.17 ± 15.6) years.
The maximum number 185 (44.2%) of patients' age was between 21
and 35years. Nearly three-fourth 321 (76.6%) of chest trauma
(18.1%) were treated non-operatively. Chest tube was inserted in
nearly two third of 271 (64.7%) of patients. Advanced procedures
such as laparotomy and thoracotomy were done for 14.3% and 2.9%
of the chest injury patients respectively. Forty-six (11%) of patients
were admitted to ICU and thirty-six (7.9%) were need mechanical
ventilation. Blood transfusion had done in thirty-four (5.5%) of
cases (Table 4).

Table 2
Injury Characteristics of study participants from June 2016 to June 30, 2020 G.C.

Status Category N (%) Out comes X2

Death Recovered

Cause of injury Violence 220 (52.5) 61 159 .572

RTA 120 (28.6) 27 93
Fall down 79 (18.9) 21 58
Severity of injury Unilateral 357 (85.2) 77 280 .000
Bilateral 62 (14.8) 32 230
Mechanism of injury Blunt 234 (55.8) 48 186 .004
Penetrating 185 (44.2) 61 124
Involved injured body region Pure chest 311 (74.2) 73 238 .044
Thoracoabdominal 108 (25.8) 36 72
Presence of associated extra thoracic injury Yes 295 (70.4) 98 197 .000
No 124 (29.6) 11 113
Associated head/neck injury Yes 91 (21.7) 44 47 .000
No 328 (78.3) 65 263
Associated abdominal injury Yes 76 (18.1) 20 56 .947
No 343 (81.9) 89 254
Associated extremities injury Yes 93 (22.2) 13 80 .003
No 326 (77.8) 96 230
Associated pelvic injury Yes 20 (3.8) 7 13 .34
No 399 (95.2) 102 297
Associated Spinal cord injury Yes 21 (5.0) 15 6 .000
No 398 (95) 94 304

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A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Table 3
Type of chest injuries presented from June 2016 to June 30, 2020 G.C

Types of injury Number of Patients Percentages Cumulative Percent

Hemothorax 96 22.9 22.9

Pneumothorax 69 16.5 39.4
Hemopneumothorax 116 27.7 67.1
Flail chest 13 3.1 70.2
Pulmonary contusion 13 3.1 73.3
Rib fracture 72 17.2 90.5
Chest wall wound 24 5.7 96.2
Diaphragmatic rupture 16 3.8 100.0

Table 4 and multicollinearity. In a multivariate analysis, the associated risk

Intervention given to chest injury patients from June 2016 to June 30, 2020 G.C factors of death identified as age above 50 years old, Time spent
Status Category N (%) Outcomes X2 between injury and admission to hospital >6hr, bilateral chest
Death Recovered
injury, penetrating chest injury, the presence of associate head/
neck, spinal cord injuries and need of mechanical ventilation, were
ICU admission Yes 46 (11) 28 18 .000
useful predictors of mortality in chest injured patients (Table 6).
No 373 (89) 81 292
Mechanical ventilation need Yes 36 (8.6) 29 7 .000 After controlling those significant factors related to outcome
No 383 (91.4) 80 303 (p < 0.05) (Table 6), death was nine times more likely happened in
Blood transfusion (units) Yes 23 (5.5) 8 15 .003 patients who were older than 50 years (AOR 9.32,95%CI 2.72e31.86,
No 396 (94.5) 97 299
p ¼ 0.000 (Table 6).
Non operative Intervention Yes 76 (18.1) 13 63 .702
No 343 (81.9) 76 210 Patients who spent >6 h before receiving health care following
Chest tube drainage Yes 271 (64.7) 64 207 .230 injury were seven times more likely to die from traumatic chest
No 148 (35.3) 45 103 injury than those arrived at health care facilities within the first 2 h
Thoracotomy intervention Yes 12 (2.9) 7 5 .010 of injury (AOR 7.17, 95% CI 1.76e29.21), p ¼ 0.006 (Table 6).
No 407 (97.1) 102 305
The presence of bilateral chest injury predicts the outcome of
Laparotomy Yes 60 (14.3) 22 38 .042
No 359 (85.7) 87 272 chest injury patients. A multivariate analysis showed that injury to
both side of chest were four times more likely to cause death than
unilateral chest injury (AOR 3.58,95% CI 1.53e8.38), p ¼ 0.003
(Table 6). Indeed, chest injury patients who had penetrating
Table 5 mechanism of injury were nearly four times risk of death than blunt
Complications developed by chest injury patients. (AOR 3.63 95% CI 1.65e7.98), p ¼ 001 (Table 6).
Status Category N (%) Outcomes X2 Moreover, the existence of associated injuries to the other re-
gion of the body determines the outcome of chest injury patients.
Death Recovered
Indeed, chest injury patients who had associated head and neck
Presence of complication Yes 148 (35.5) 59 89 .000 injury were four times more likely to die than their counterparts
No 271 (64.5) 50 221
(AOR 3.56, 95% CI 1.31e9.72). Also, patients who had associated
Pneumonia Yes 58 (13.8) 25 33 .001
No 361 (86.2) 84 277 spinal cord injury were five times more likely to die than their
wound sepsis Yes 38 (9.1) 20 18 .000 counterparts (AOR 4.8, 95% CI 1.13e20.47) (Table 6).
No 381 (90.9) 89 292 Traumatic chest injury Patient who needs artificial ventilation
Atelectasis Yes 53 (12.6) 14 39 .943
via mechanical ventilators were eleven times more likely die than
No 366 (87.4) 95 271
those who didn't need mechanical ventilation (AOR 11.18, 95% CI
2.11e59.23) (Table 6).

3.4. Complications
The majority 271 (64.5%) of chest injury patients were treated
without developing complications while nearly, one third of 148
(35.5%) had complications in hospital. These complications
included pneumonia 58 (13.8%), atelectasis 53 (12.6%) and wound
sepsis 38 (9.1%) (Table 5).
3.5. Mortality
The overall mortality in patients with traumatic chest injury was
109 (26.0%). The result demonstrates the correlation between old
age, time of presentation to the hospital, penetrating injury, bilat-
eral chest injury, associated extra-thoracic injuries to (spinal cord
injury and head/neck) and need for mechanical ventilation.
3.6. Predictors of mortality among chest injury patients
The logistic regression results for mortality risk factors are listed
on Table 6. There were no violations of assumptions of normality
4
4. Discussion
A retrospective study done in Syria showed; Mortality occurred
in 1.8% of patients. The first etiology of chest injuries was violence
(41%) then by road traffic accident (33%). The most frequent types of
chest injury were; pneumothorax (51%), hemothorax (38%), rib
fractures (34%), and lung contusion (15%). Besides, extra-thoracic
injuries occurred in 35% of patients [26].
According to the study conducted in United Arab Emirates on
chest trauma patients the mortality rate was 7.2%. The primary
cause of injury was road traffic events (66%) followed by falls
(23.4%). From the total of study subjects about (36.5%) had isolated
chest injury, but the remaining had associated head injury (27.4%)
and extremities (50%). mortality was associated with severe head
injuries (p < 0.0001) and low systolic blood pressure on arrival
(p ¼ 0.027)[27].
In this study 419 eligible chest injured patients were admitted to
the hospital during the study period and the mortality rate has
been found as 26.0% (95% CI: 21.7.0e30.5). This figure is comparable
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Table 6
Multivariate Logistic Regression Analyses for Factors associated with mortality after chest trauma.

Variables N (%) Odds ratio (95% CI)

COR (95% CI) AOR (95% CI)

Age <20 63 (15) 1 1

21e35 185 (44.2) 1.37 (0.64e2.94) 1.44 (0.52e4.02)
36e50 95 (22.7) 2.82 (1.27e6.26) 2.74 (0.90e8.39)
>50 76 (18.1) 3.09 (1.36e7.03) 9.32 (2.72e31.86)***
Time between injury and admission (hr.) <2 53 (12.7) 1 1
2e6 192 (45.8) 3.22 (1.10e9.47) 3.22 (0.75e13.73)
>6 174 (41.5) 7.31 (2.52e21.18) 7.17 (1.76e29.21)**
Severity of injury Unilateral 357 (85.2) 1 1
Bilateral 62 (14.8) 3.88 (2.22e6.78) 3.58 (1.53e838)**
Mechanism of injury Blunt 234 (55.8) 1 1
Penetrating 185 (44.2) 1.91 (1.23e2.96) 3.63 (1.65e7.98)***
Presence of associated extra thoracic injury Yes 295 (70.4) 5.11 (2.63e9.94) 4.80 (1.47e15.72)**
No 124 (29.6) 1 1
Associated head and neck injury Yes 91 (21.7) 3.79 (2.31e6.20) 3.56 (1.31e9.72)*
No 328 (78.3) 1 1
Associated Spinal cord injury Yes 21 (5.0) 8.09 (3.05e21.43) 4.80 (1.13e20.47)*
No 398 (95) 1 1
Mechanical ventilation need Yes 36 (8.6) 15.69 (6.63e37.13) 11.18 (2.11e59.23)**
No 383 (91.4) 1 1

Note: *p < 0.05, **p < 0.01, ***p < 0.001 AOR: Adjusted Odds Ratio; COR: Crude Odds Ratio.

to a result reported by Baru et al. 27.6%, Massaga F.A et al. 24.2% and
Sanjay Datey et al. 22.23% respectively [9,28,29]. But much higher
than studies reported by Al-Koudmani et al., and Al-Eassa EM et al.
and Khursheed SQ et al. [12,26,30] This discrepancy may be due to
different care treatment standards.
Our study found that chest trauma predominantly affects male
and young age. This finding is consistent with results reported by
other studies[12,15,31,32]. The reason for this observation might be
males and younger ages were engaging in high-risk activities more
than elder and females. However, chest trauma to old age patients
has been found to be predictor factor for death. Indeed, Patients
aged >50 years were nine times more likely die from chest injury
than those aged below 20 years (AOR 9.32). Other recent studies in
line with this finding[28,33].
Our study found that most of patients were presented to health
care facilities in the time period of 2e6 h of injury (45.8%) and after
6 h (41.6%). Rajesh K. Jegoda et al. reported the average time spent
between the event and admission was 11 h and 12 min[31].
Furthermore, late presentations (>6hrs) to health care center were
associated with mortality in this study (AOR 7.17, 95% CI
1.76e29.21). Similar to our result with AOR 4.6, 95% CI 1.19e18.00
showed patients that were arrived to the hospital later had higher
mortality rate than those who were arrived earlier[28]. The reason
could be absence of systematized ambulance service with first re-
sponders and a lack of trauma center in the country accounted for
few numbers of patients were arrived within the early hours of
injury.
In agreement with the other study we found that majority of
victims were injured by violence followed by Road traffic accidents
(RTA) [4]. Assault were the leading cause of injuries and responsible
for 52.5% of all injuries. However, this figure is higher than study
reported by Al-Koudmani et al. 41%[26]. The reason to such high
figures might be due to increased assaults in this study area.
Blunt chest injuries were more common than penetrating chest
injuries 55.8% vs 44.2%. This finding was in line with previous
studies from Uganda 57.7%, Nigeria 53%[11,32]. The result of this
study is much lower than the study conducted in United Arab
Emirates 66%, another study Nigeria 69.7% and Tanzania 75.6%
[9,30,34]. This difference may be due to the difference in causes of
injury. Even though, penetrating chest trauma is less common than
blunt trauma, it was more deadly[35]. Penetrating chest injury
associated with mortality among chest injury patients with (AOR
3.63 95% CI 1.65e7.98). This is in accordance with other studies
reported by Ali et al. [36].
In our study unilateral chest injury occurs more commonly.
However, patients having bilateral chest trauma is significantly
associated with a higher risk of mortality than unilateral chest
injury (AOR 3.58, 95% CI 1.53e8.38). Ekpe EE et al. reported similar
finding[15].
Regarding the type of chest injury, majority of the patients had
hemopneumothorax 116 (27.7%) whereas hemothorax and rib
fracture were diagnosed in 96 (22.9%) and 72 (17.2%) cases
respectively. This result was consistent with the study done in
Addis Ababa reported as hemopneumothorax was commonest type
of chest injury[37]. However, other studies from Ethiopia, Uganda
and India reported as rib fracture was the commonest types of chest
injury[12,31,38]. The disparity might be related with the difference
in cause of injury. But this is not statistically significance amongst
the types of chest injuries on outcome analysis.
Our study found that 70.4% of patients had associated extra-
thoracic injuries. This finding was nearly consistent with the
result of the study conducted in Uganda 64.8% and Tanzania 61.3%.
Interestingly, injury other than spinal cord and head/neck injury
didn't significantly correlate with the mortality rate. Similar to
others, our result showed that, spinal cords injury (P ¼ 0.034) and
head/neck injury (p ¼ 0.013) statically associates with mortality
[28]. In this study head injuries were 21.7% which was almost
similar with the studies in Tanzania 21.8% and Sudan 19%[9,39].
In our study majority of the patients (81.9%) received surgical
management, of whom 64.7% chest tube drainage, 14.3% explor-
atory laparotomy and 2.9% underwent thoracotomy. The remains
which were 18.1% of patients needed none operative intervention
in the form of chest physiotherapy and analgesics. This finding is
comparable to Khursheed SQ et al. chest tube was done in 65%,
thoracotomy 3.75%[12]. However, our result was low from study
reported by Rajasekhar N. et al. chest tube was done in 75.35%,
thoracotomy 5.56%. The difference may be presence of more
experienced thoracic surgeons[23].
In this study 8.6% of patients require supportive mechanical
ventilation among chest trauma patients. This is much lower than
the study conducted India,18.68%.The disparity may be the severity
of traumatic chest injury[23]. The need for mechanical ventilation

5
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al.
was also among the factors associated with increased mortality in
chest trauma patients, p ¼ 0.01, which is agreed by a study of
Refaely Yael et al. p ¼ 0.01[40].
Similar to others our study found that pneumonia was the
leading cause of complications. In contrast to this findings from
Ugandan study the incidence was low[11]. Even though we have no
specific data to clarify the reasons why those patients not correlate
with high mortality. On the other hand, study from India showed
atelectasis was the most common morbidity. Surprisingly, in this
study the presence of complications was not associated with
mortality. The reason might be due to aggressive initial treatment
of those specific morbidity and standard of care provided.
5. Conclusion and recommendations
The mortality rate in traumatic chest injury was high. Late
presentation beyond 6hr, age >50-year, penetrating injury, Bilateral
chest injury, associated extra thoracic injury and need of mechan-
ical ventilation were identified as possible risk factors for mortality
in traumatic chest injury patients.
We recommend development of standard care practices and the
trauma team needs a better preparation to provide effective
treatment strategies when encountering traumatic chest injured
patients. The mortality varies by the pattern of injury with the
highest among victims of violence. This suggests the need for
awareness creations to society on their health seeking behavior and
conflict resolution programs. Establishment of organized pre-
hospital services and provision of a sustainable ambulance ser-
vice with trained staff is recommended.
Acronyms and abbreviations
AOR: Adjusted Odd Ratio, OR: Cured Odd Ratio, G.C: Gregorian
calendar, GCS: Glasgow comatose score, ICU: Intensive Care Unit,
LOS: Length Of stay, RTA: Road Traffic Accident, SD: Standard De-
viation, SPSS: Statistical Package for the Social Sciences.
Limitations
Since it was a retrospective study we were not directly observes
patients’ condition including their vital sign and treatment inter-
vention. Though we were only focused on what was documented
on patients chart. As much as possible we were trying to avoided
incomplete, unclear and ambiguous documents. Even if mortality is
an indicator of trauma burden, many more survivors are left with
permanent disability. We did not have access to long-term out-
comes to show the full picture of the trauma burden. Further
studies may require for looking long-term outcomes of chest
trauma patients.
Sources of funding
Self-sponsorship and funded.
Ethical approval
Ethical approval was obtained from ethical committee board of
university of Gondar specialized Hospital.
But reference number is not necessary it is already approved.
Consent
Not applicable since it is retrospective study.
6
International Journal of Surgery Open 37 (2021) 100420
Author contribution
Authors' contributions: This work was carried out in collabo-
ration among all authors. AE contributed to the conception and
design of the study, acquired; analyzed and interpreted the data
drafted and revised the manuscript. SY, AH and HA participated in
reviewing the design and methods of data collection, interpretation
and preparation of the manuscript. All authors participate in
preparation and critical review of the manuscripts. In addition, all
authors read and approved the manuscript.
Registration of research studies
researchregistry7105.
Guarantor
Salh Yalew Mustofa, Abubeker Eshetu Yimam, Amare H/kiros
Gebregzi, Habtu Adane Aytolign.
Declaration of competing interest
The author declares there is no conflict of interest.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.ijso.2021.100420.
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