Chest injury due to blunt trauma.

OBJECTIVE: Given its importance in trauma practice, we aimed to determine the pathologies associated with blunt chest injuries and to analyze the accurate identification of patients at high risk for major chest trauma. METHODS: We reviewed our experience with 1490 patients with blunt chest injuries who were admitted over a 2-year period. Patients were divided into three groups based on the presence of rib fractures. The groups were evaluated to demonstrate the relationship between the number of rib fractures and associated injuries. The possible effects of age and Injury Severity Score (ISS) on mortality were analyzed. RESULTS: Mean hospitalization time was 4.5 days. Mortality rate was 1% for the patients with blunt chest trauma, 4.7% in patients with more than two rib fractures and 17% for those with flail chest. There was significant association between the mortality rate and number of rib fractures, the patient's age and ISS. The rate of development of pneumothorax and/or hemothorax was 6.7% in patients with no rib fracture, 24.9% in patients with one or two rib fractures and 81.4% in patients with more than two rib fractures. The number of rib fractures was significantly related with the presence of hemothorax or pneumothorax. CONCLUSION: Achieving better results in the treatment of patients with chest wall injury depend on a variety of factors. The risk of mortality was associated with the presence of more than two rib fractures, with patients over the age of 60 years and with an ISS greater than or equal to 16 in chest trauma. Those patients at high risk for morbidity and mortality and the suitable approach methods for them should be acknowledged.     

Chest Trauma in Children, Single Center Experience

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%) and flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was (7.2%) and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality.     

Thoracic trauma in children: an indicator of increased mortality

This study was undertaken to assess the significance of thoracic trauma as a marker of morbidity and mortality in children. During a 34-month period, 2,086 children younger than 15 years old were consecutively admitted to a Level I pediatric trauma center with blunt or penetrating trauma. For each child we prospectively recorded Trauma Score (TS), Injury Severity Score, (ISS), medical, and etiologic data. One hundred four children (4.4%) presented with thoracic trauma. The most common mechanisms of injury were pedestrian injury (36%), motor vehicle crashes (32%), and armed assault (12%). The most common injuries were pulmonary contusion (48%), pneumothorax, hemothorax, or pneumohemothorax (39%), and rib fractures (32%). Multisystem injury was present in 82% of the children. The mean TS and ISS were 11 and 27, respectively, significantly worse than scores for children without thoracic injury (15 and 7; P less than .0001). Seventy-one percent of the children were admitted to the intensive care unit, where they stayed an average of 6 days; 20% required surgery. The mortality rate was 26%. Injuries to the heart or great vessels had the highest mortality rate (75%), followed by hemothorax (53%), lung laceration (43%), and rib fracture (42%). Mortality for children with isolated chest injury was 5%, compared with rates of 20% for abdominal and chest trauma, 35% for head and chest trauma, and 39% for trauma to the head, chest, and abdomen. Less than 5% of the admissions to a pediatric trauma center incurred thoracic injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Factores pronóstico del traumatismo torácico: estudio prospectivo de 500 pacientes

ObjectiveIdentify the factors of greatest impact in patients with chest trauma.Patients and methodsprospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects.ResultsThe presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity.ConclusionsThoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years.     

Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle accidents.

One hundred twenty-eight cases of chest injury were seen in a Paediatric Trauma Unit over a 5 1/2-year period. One hundred patients sustained motor vehicle accident (MVA)-related blunt chest injuries, 91 of them as pedestrians. Nine children had blunt chest injuries from falls, 10 had stab wounds (3 assault, 7 accidental), and 9 had gunshot injuries (6 from birdshot used by police during civil disturbance). MVA-related injuries were studied separately, as an etiologically homogeneous group. Sixty-five of these patients were under the age of 6. All but 3 also had serious extrathoracic injuries. The mean injury severity score (ISS) in MVA-related injuries was 25. Eight patients died, all with an ISS of 34 or more, 7 of whom had fatal head injuries. In MVA-related injuries, pulmonary contusion (n = 73) was the most frequent lesion seen, followed by rib fracture (n = 62), posttraumatic effusion (n = 58), pneumothorax (n = 38), and pneumatocele (n = 5). In MVA-related injuries, 18 children required ventilation. Thirty-nine (69%) of 56 children with radiologically evident posttraumatic pleural effusion had intercostal chest drainage. Analysis suggests that lung injury is a central event in MVA-related blunt chest trauma. Primary lung injury, radiologically visible as contusion, is complicated by hematoma, posttraumatic effusion, and pneumothorax.     

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 importance 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 pulmonary injuries, and these require urgent intervention. 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 patient, it is important to understand the treatment 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.     

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.     

Selective management of flail chest and pulmonary contusion.

Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.     

The unchanged mortality of flail chest injuries.

Six hundred eighty-five patients with major blunt thoracic injuries from 1968 through 1977 were retrospectively studied. This series was compared to a similar series from 1959 through 1964. Between 1964 and 1968 a vastly improved hospital was built, laboratory support improved, pressure-controlled ventilators replaced by volume-controlled ventilators and the trauma service was reorganized. The treatment regimen for flail chest injuries during the last decade evolved from the previous early tracheostomy and prolonged ventilator support to an avoidance of tracheostomy and brief ventilator support. The overall mortality in the present series was 20% compared to 35% for the 1959--1964 series; however, improved mortality occurred only among patients with hemothorax who had one or more major concomitant extrathoracic injuries. The mortality for flail chest injuries did not improve (29.5 vs 35.0%). Mortality was unchanged for isolated flail chest injuries, isolated pneumothorax, isolated hemothorax, and for flail chest injuries, and pneumothorax in patients with concomitant major extrathoracic injuries. In both series deaths from isolated thoracic injuries were rare. It is evident that the continued high mortality for blunt thoracic trauma principally relates to concomitant extrathoracic injuries and that recent treatment innovations have not reduced the mortality of flail chest injuries.     

Prolaps des rechten Lungenmittellappens über eine grob dislozierte Sternumquerfraktur

In cases of multiple trauma in patients with an injury severity score (ISS) ≥16 chest injuries, abbreviated injury scale (AIS) ≥3, are also sustained in 57.2% of all patients. Life-threatening complications may occur with lung contusions and rib fractures also in combination with hemothorax/pneumothorax being the most common diagnoses. In addition the lungs can also be functionally impaired by ruptures of the great thoracic vessels or in isolated cases by herniation of lung tissue following tears in the wall of the thorax. A case of multiple trauma in a 44-year-old male (ISS 29) with blunt thoracic trauma resulting in herniation of the middle lobe of the right lung into the subcutaneous tissue due to a coarsely dislocated fracture of the sternum is reported. This still ventilated lung tissue was surgically resituated 4 weeks after the event and the sternum fracture was simultaneously stabilized by plate osteosynthesis. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential. Therefore, standard diagnostic procedures combined with multislice computed tomography during the first examination and reassessment should be included to avoid missed injuries.     

A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.

OBJECTIVE: A rib fracture secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. In the present study we explored the morbidity and mortality rates and the management following rib fractures. METHODS: Between May 1999 and May 2001, 1417 cases who presented to our clinic for thoracic trauma were reviewed retrospectively. Five hundred and forty-eight (38.7%) of the cases had rib fracture. There were 331 males and 217 females, with an overall mean age of 43 years (range: 5-78 years). These patients were allocated into groups according to their ages, the number of fractured ribs and status, i.e. whether they were stable or unstable (flail chest). RESULTS: The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31). CONCLUSIONS: Rib fractures can be interpreted as signs of significant trauma. The greater the number of fractured ribs, the higher the mortality and morbidity rates. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is three or more. We also advocate that elderly patients with six or more fractured ribs should be treated in intensive care units due to high morbidity and mortality.     

The sensitivity of chest X-ray (CXR) for the detection of significant thoracic injury in children exposed to blast

IntroductionThoracic trauma is an important cause of morbidity and mortality in children exposed to blast and early recognition of these injuries is vital. While numerous studies have investigated the sensitivity of chest X-ray (CXR) for the detection of chest injury in blunt trauma, none have evaluated its performance in paediatric blast injury.MethodsCXR and Computed Tomography (CT) thorax findings were compared for 105 children who were injured by blast and presented to the UK Role 3 Hospital, Camp Bastion, Helmand Province, during the recent conflict in Afghanistan from 2011 to 2013. CXR performance was evaluated compared to the ‘gold standard’ of CT for the detection of significant thoracic injuries, defined as pneumothorax, haemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, penetrating fragments and pulmonary contusion or laceration.ResultsThe sensitivity of CXR for the detection of significant injuries was: pneumothorax 43%, haemothorax 40%, contusion 44%, laceration 100%, blast lung 80% and subdermal metallic fragments 75%. CXR missed all cases of diaphragm injury, ≥2 rib fractures, clavicle fracture and pleural effusion, although numbers of each were small. Specificity for CXR injury detection was 94% for contusion and 93% for fragment, and 100% otherwise. The sensitivity and specificity of CXR for identifying an abnormality that would prompt CT imaging was 72% (95% CI 55–85%) and 82% (95% CI 70–90%).ConclusionsCXR has a poor sensitivity for the identification of significant thoracic injury in children exposed to blast. We argue that, given the challenge of clinical assessment of injured children and the potential for serious adverse consequences of missed thoracic injuries, there should be a low threshold for the use of CT chest in the evaluation of children exposed to blast.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Chest Injuries in Polytrauma

Abstract Background and Purpose: Blunt chest injuries are commonly seen in polytrauma patients and are known to be associated with higher mortality and morbidity. The objectives of the present study are to assess the effect of blunt chest injury concerning morbidity, mortality as well as clinical courses and outcome of multiply injured patients with chest trauma. Patients and Methods: This study includes all polytrauma patients with chest injury treated between 1992 and 2002 at a major urban trauma center. Parameters examined included injury pattern, injury severity, mortality, hemodynamics at admission, duration of ventilation, length of stay in intensive care unit (ICU), and outcome. Results: 332 out of 501 polytrauma patients, 228 males and 104 females, had a coexisting chest injury. Mean age at the time of injury was 37.7 years, and 258 patients were intubated before admission. Average period on ICU was 15.4 days, and 35.9 days for total hospital stay. Regarding the injury pattern in 143 patients a combined hemo-/pneumothorax was seen, 109 patients had either a hemothorax or a pneumothorax, in 155 patients a unilateral and in 52 patients a bilateral serial rib fracture was diagnosed, in 28 patients either sternal or singular rib fractures were determined, in a total of 23 patients an unstable thorax or a flail chest was seen, 105 patients had a unilateral pulmonary contusion, and in 79 patients a bilateral pulmonary contusion was diagnosed. Finally, a total of eleven patients with a traumatic aortic disruption were identified. Conclusion: The present study shows that chest injuries in polytrauma patients are common coexisting injuries and contribute significantly to the morbidity and outcome of these patients. Early intubation and ventilation in combination with an adequate circulatory stabilization are crucial to avoid complications and deleterious outcome.     

Rib fractures in children: a marker of severe trauma

The early recognition of life-threatening injury is paramount to the prompt initiation of appropriate care. This study assesses the importance of multiple rib fractures as a marker of severe injury in children. We analyzed physiologic, etiologic, and injury data for 2,080 children with blunt or penetrating trauma aged 0-14 years consecutively admitted to a Level I pediatric trauma center. Analysis of variance, Student's t-test, and the Chi-square test of independence were used to test for differences between children with rib fractures and other children. Probability of survival was modeled using stepwise logistic regression. There were 14 deaths among 33 children with rib fractures, a mortality rate of 42%. Child abuse accounted for 63% of the injuries to children less than 3 years old, while pedestrian injuries predominated among older children. Children with rib fractures were significantly more severely injured than children with blunt or penetrating trauma but without rib fractures. When compared to children without rib fractures, children with rib fractures had a higher mortality rate, but no statistically significant difference in morbidity. The mortality rate for the 18 children with both rib fractures and head injury was 71%. A logistic model with variables measuring severity of head injury and number of ribs fractured correctly predicted survival in more than 85% of children with thoracic trauma. Although rib fractures are rare injuries in childhood, they are associated with a high risk of death. The risk of mortality increases with the number of ribs fractured. The combination of rib fractures and head injury was usually fatal.     

Management of 150 flail chest injuries: analysis of risk factors affecting outcome.

OBJECTIVE: Flail chest continues to be an important injury with significant complications. The records of 150 patients presenting with flail chest injury were reviewed to determine risk factors affecting morbidity and mortality. MATERIAL AND METHOD: During a 7-year period 150 patients with a flail chest injury were admitted to our trauma center. There were 111 men (74%) and 39 women (26%) ranging in age from 18 to 88 years with a mean age of 56.9. Only 66 (44%) had an isolated flail chest injury on admission. The majority of patients were older than 55 years (n = 89, 59.3%), 80 (53.3%) presented with an hemo-, or/and pneumothorax, 36 (24%) sustained a head injury and 25 (16.7%) needed ICU monitoring. The mean ISS score was 38. Age, concomitant diseases, presence of pneumothorax and/or hemothorax, Severity Score (ISS), the need for mechanical support, length of stay and deaths were evaluated by using the t-test and chi2 test where appropriate. RESULTS: Sixty-seven patients (44.6%) were conservatively treated, while 80 (53.3%) needed thoracic drainage. Only in 6 cases (4%) thoracotomy was required, while in 9 (6%) laparotomy was performed. Mortality rate reached 5.3%. The main factors correlated with an adverse outcome were: ISS and the presence of associated injuries, while age, hemopneumothorax and mechanical support affected the length of hospitalization but not the mortality. CONCLUSIONS: (1) Age and hemopneumothorax did not affect mortality. (2) ISS was found to a strong predictor on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate. (3) Mechanical support was not considered a necessity for the treatment of flail chest.     

Intraabdominal organ injury due to blunt chest trauma —Report of two cases—

Two cases of intraabdominal organ injuries due to blunt chest trauma are reported. A 58-year-old man was admitted to our hospital with multiple rib fractures, hemopneumothorax and left flail chest. An emergency operation was performed and intraoperative findings revealed that the fractured rib was penetrating through the diaphragm to the stomach. A 52-year-old woman was admitted to our hospital with left multiple rib fractures and hemopneumothorax. Her treatment included chest tube drainage, but a week after admission, intraabdominal bleeding occurred due to a ruptured spleen, necessitating an emergency operation (splenectomy). Blunt chest trauma injury is usually accompanied by multisystem injury. Therefore, it is important to detect intraabdominal injury during an emergency operation and the follow-up period.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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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.     

Chest trauma

This article describes the life-threatening chest and mediastinal injuries seen in patients with blunt and penetrating trauma. It describes the clinical features of these injuries and their initial management, and also considers the imaging that can be used to confirm the diagnosis and plan ongoing management. The injuries discussed include tension pneumothorax, massive haemothorax, cardiac tamponade, flail chest and open pneumothorax. The presentation and management of other significant chest injuries, namely traumatic aortic dissection, pulmonary contusion and myocardial contusions, are also described. The article also suggests when cardiothoracic surgical consultation may be useful in the management of these patients.