Blunt and penetrating chest injuries

The management of chest injuries begins with knowledge of what happened to the patient at the time of the traumatic incident and converting this information into possible diagnoses. The various organs of the chest cavity are discussed emphasizing the controversies that attend the management or diagnosis of each one.

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Resumen El trauma torácico constituye entre el 20 y el 30% de todas las muertes por trauma en los Estados Unidos; sin embargo, sólo 15% de los pacientes con trauma torácico requieren intervención quirúrgica. La mayoría de los casos pueden ser exitosamente manejados manteniendo oxigenación y perfusión adecuadas. La estabilidad de la pared torácica, el control de neumotórax y de hemotórax masivo y el mantenimiento de buen gasto cardiaco aseguran la oxigenación tisular que previene el metabolismo anaeróbico. La hemorragia, que generalmente se origina en la pared torácica o en los vasos pulmonares, con frecuencia es autolimitante. Las lesiones de la aorta que resultan en pérdida de continuidad de la luz vascular y las lesiones cerradas del corazón deben ser manejadas como entidades independientes, aunque hacen parte del complejo patológico que se conoce como trauma torácico. Las lesiones del esófago son poco comunes pero requieren reparación en la misma forma que en cualquiera otra parte del tracto gastrointestinal. La presente revisión de las lesions torácicas comprende: 1) lesiones de la pared torácica; 2) lesiones de los pulmones y bronquios, incluyendo los vasos pulmonares; 3) lesiones del corazón; 4) lesiones de la aorta, y 5) lesiones del esófago. Se hace énfasis sobre las controversias que suscitan el manejo y el diagnóstico de estas lesiones.

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Résumé Le traitement des lésions thoraciques commence par la compréhension du type du traumatisme et la discussion diagnostiques possibles. Les organes de la cavité thoracique pouvant être lésés sont énumérés et les controverses entourant leur diagnostic ou leu traitement sont discutés une par une.

     

Clinical features of traumatic diaphragmatic injuries with or without herniated visceral organs

The difficulty of diagnosis and selection of operative approach in traumatic diaphragmatic injuries (T. D.I.) have been debated for a long time. The reason why these problems remain unsolved is possibly due to the inaccuracy in the definition of T.D.I. We propose to classify the T.D.I. into two categories; diaphragmatic rupture without herniated visceral organs (D.R.) and diaphragmatic hernia with herniated visceral organs (D.H.). Clinical features in these two groups (D.R. in 9 cases and D.H. in 11 cases) were compared and discussed as follows: 1) Intrathoracic injuries were associated in all cases of both groups, but intraabdominal injury was found in 90.9% of D.H., whereas 33.3% of D.R. 2) Diagnostic findings in chest X-ray were not observed in D.R., but frequently observed in D.H. 3) All cases of D.R. were operated through a single approach (transabdominal or transthoracic), but additional approach was necessary in 78% of D.H. It is considered that T. D.I. should be classify into D.R. and D.H. because T.D.I. with or without herniated visceral organs exhibit definitely different clinical features.     

Blunt trauma with flail chest and penetrating aortic injury.

Blunt chest trauma with flail chest is common. The mortality attributes initially to the associated pulmonary contusion, massive hemothorax and later to the occurrence of adult respiratory distress syndrome. We report a case of flail chest with segmental fractures near the costovertebral junction and delayed hemothorax attacked 14 h later. The final diagnosis of the penetrating aortic injury by detached rib fragment was appreciated by aortogram. Unfortunately, active aortic hemorrhage made prompt thoracotomy in vain for life salvage.     

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS: A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS: One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS: In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.     

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 percent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.     

Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries

BACKGROUND: The diagnostic workup in stable patients with penetrating thoracoabdominal injuries can be extremely difficult. Conventional diagnostic tests such as plain chest radiography, computed tomography scan, digital exploration, and diagnostic peritoneal lavage can be misleading. Classically, most of these patients have undergone exploratory laparotomy to determine whether there is a diaphragmatic injury. METHODS: In this study, 52 patients with penetrating thoracoabdominal trauma, and without any indication for immediate surgery, underwent video-assisted thoracoscopy to determine the presence of diaphragmatic injuries. RESULTS: Of the 52 patients, 48 were men. The left hemithorax was involved in 38 patients (73%). Chest x-ray was normal in 40 patients (77%) who were clinically asymptomatic. Stab wounds were responsible for 80% of the injuries. At the time of the thoracoscopy, 35 patients (67%) were found to have a diaphragmatic injury. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. The procedure was completed in 50 patients (96%). There were no deaths or complications. CONCLUSIONS: The incidence of diaphragmatic injuries is higher than anticipated in asymptomatic patients with penetrating thoracoabdominal wounds. Video thoracoscopy can be used as a safe, expeditious, minimally invasive, and extremely useful technique to facilitate the diagnosis of these injuries in asymptomatic patients. Furthermore, diaphragmatic injuries can be repaired easily through a thoracoscopic approach with no complications.     

Antibiotic prophylaxis in penetrating injuries of the chest.

Most prospective studies recommend antibiotic prophylaxis whilst a thoracostomy tube is in place or even longer. We conducted a randomised study of 188 patients with penetrating chest injuries requiring a chest drain. Of these patients, 95 received a single dose of ampicillin before insertion of the chest tube, the remaining 93 patients received additional antibiotic prophylaxis for as long as the drain was in place. The incidence of intrathoracic sepsis (pneumonia or empyema) was 3.1% and 3.2%, respectively. It is concluded that single-dose prophylaxis in penetrating chest trauma is as effective as prolonged prophylaxis. The importance of chest physiotherapy immediately after the drain insertion and of early removal of the drain is stressed. The role of various possible risk factors in the development of sepsis is discussed.     

Reliability of physical examination in penetrating chest injuries

The decision to insert an intercostal drain in chest injury must occasionally be made without a chest radiograph. A prospective analysis of the reliability of physical examination in penetrating pleural injuries was undertaken. A total of 51 consecutive patients were examined before obtaining a chest radiograph. The presumptive diagnosis and decision to institute intercostal drainage were compared with the radiological diagnosis and the actual decision in each patient. A policy of selective drainage of large pleural collections was employed. The series consisted mainly of stab injuries in young men. Physical examination accurately diagnosed 13 of the 14 large pneumo- or haemothoraces. This reliability combined with the selective drainage policy showed that physical examination accurately predicted the need for tube thoracostomy with a sensitivity of 96 per cent and a specificity of 93 per cent. This study suggests that experienced clinicians should not hesitate to institute immediate lifesaving intercostal drainage when needed, before a chest radiograph is obtained.     

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life.Although it is the third most common cause of death in all age groups,one out of four trauma patients die due to thoracic injury or its complications.Blunt injuries constitute the majority of chest trauma.This indicates the im porta nee of chest trauma among all traumas.Blunt chest trauma is usually caused by motor vehicle accident,falling from height,blunt instrument injury and physical assault.As a result of chest trauma,many injuries may occur,such as pulm onary injuries,and these require urge nt in terve ntion.Chest wall and pulmonary injuries range from rib fractures to flail chest,pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries.Following these injuries,patients may present with a simple dyspnea or even respiratory arrest.For such patie nt,it is imports nt to understa nd the treatme nt logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries.This is because only 10%of thoracic trauma patients require surgical operation and the remaining 90%can be treated with simple methods such as appropriate airway,oxygen support,maneuvers,volume support and tube thoracostomy.Adequate pain control in chest trauma is sometimes the most basic and best treatment.With definite diagnosis,the morbidity and mortality can be significantly reduced by simple treatment methods.     

Intercostal herniation of abdominal contents following a penetrating chest injury.

A case of intercostal herniation of the greater omentum occurring 36 years after a penetrating chest injury is presented. The hernia was successfully treated by operative reduction and repair of the diaphragm and chest wall. This rare complication of thoracic injury is discussed and the literature reviewed.     

Retrocardiac herniation of atelectatic lung into the opposite chest

A 64-year-old man with a history of esophageal adenocarcinoma status postneoadjuvant therapy underwent esophagogastrectomy. Postoperatively he was found with increasing dyspnea and oxygen requirements. Computed tomography of the chest showed retrocardiac herniation of atelectatic lung into the contralateral hemithorax.     

Splenic injury from gunshot wounds to the chest without diaphragmatic or peritoneal violation: case reports

Three cases of isolated splenic injury without peritoneal penetration are described. Two patients were explored because of bullet trajectory, one was explored because of a positive physical examination. Two patients had minor splenic injuries. One required splenorrhaphy. A review of intraperitoneal injury from extraperitoneal gunshot wounds is presented.     

胸腹联合伤的早期诊断与治疗

目的　总结胸腹联合伤早期诊断与治疗的经验。方法　对42例胸腹联合伤患者的临床资料进行回顾性分析。结果　伤后24h内入院者40例,48～72h入院2例。胸腹部开放性损伤8例,胸腹部闭合性损伤34例(包括膈肌破裂并腹部脏器损伤)。术前确诊38例(90%)。42例均在入院后24h内手术。治愈40例;死亡2例(48%)。结论　胸腹联合伤一般都有合并伤和伤后出现并发症,病情凶险,因此对胸腹联合伤必须迅速正确地诊断和处理,尤其合并严重胸外伤、出现呼吸功能不全者。     

Comprehensive clinical x-ray-radionuclide study of lung function in penetrating chest injuries

Results of the complex clinico-x-ray-radionuclide research of 52 patients with penetrating injuries of the chest have shown that the morphological and functional state of the injured lung can be assessed by findings of rheography, spirography, scanning and scintigraphy, roentgenography and roentgenoscopy.