Errors and complications in penetrating thoracic injuries

Examination, treatment, and postoperative complications in 286 patients with penetrating chest injuries are analysed. Errors in the diagnosis and treatment were disclosed in 104 (36.4%) cases. All of the wounded were operated on, a total of 490 operations were carried out. Complications occurred in 69 (14.1%) patients. Sixteen (5.6%) patients died. Diagnostic errors were made in 28 patients, tactical in 25, technical in 51, faulty postoperative management was revealed in 18 patients. A connection between the errors and complications was established in 52 cases with complications (75.4%). Gross fatal errors were made in 7 of 16 patients who died.     

Videothoracospy in thoracic trauma and penetrating injuries

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.     

Septic complications of penetrating thoracic injuries

224 cases of septic complications after penetrating thoracic injuries were analyzed. Pleura empyem was observed in 105 of 7572 patients (overall number of the injured), lung abscess - in 22 cases, pericarditis was diagnosed in 108 patients, costal and sternal osteomyelitis - in 26 and mediastinitis - in 21 patients. Overall frequency of septic complication was 2,96%. Main reasons of septic complications were: massive blood loss, initial contamination, thoracotomy through the initially infected wound, long -lasting and coagulated hemothorax and late diagnosis and hospitalization. Staphylococcus aureus was the most frequent microbe detected - 29,4%. Lethality rate was 9,8% (22 patients). Adequate drainage of the wound allowed rehabilitation of the majority of patients. Cases with costal osteomyelitis required major surgical dissection in 73,1%.     

Clinical study of penetrating thoracic injuries

During the 13-year period ending in December 1987, 39 patients (pts) of penetrating thoracic injuries were treated. Thirty-five pts (89.7%) were male, and the age range was 21 to 56 years with average of 38.7 years. Thirty-one pts (79.5%) sustained stab wounds and eight (20.5%) had gun-shot wounds. 5 pts died in all (2 pts with stab wounds, 3 with gun-shot wounds). The wounds were limited on chest wall in 14 pts, and penetrated to thorax in 25. In these pts with penetrating wounds, lung injuries were found in 18, heart in 7 and esophagus in 1, respectively. Twenty-one pts had multiple injuries, and abdominal injuries were found in 20 pts (95.2%), limbs in 7 (33.3%), and neck in 2 (9.5%). All 5 dead pts had multiple injuries. Prognoses were fair in cases of simple chest wall injuries or lung injuries. In the cases of lung injuries, thoracotomy was performed in 8 pts (44.4%) and tube thoracostomy in 10 (55.6%). Thoracotomy was performed for massive bleeding (over 600 ml/1-2 hours) (6 cases) and the sites of the injuries suspecting of heart injuries (2 cases). Two pts undergoing tube thoracostomy and one pt done thoracotomy died, but the causes of the death were not related to lung injuries. Regarding the heart injuries, the injured sites were left ventricle in 1, right ventricle in 1, right atrium in 2, and pericardium in 3. All the 7 pts were in shock on arrival. In these pts with heart injuries, all the wounds were in and near the Sauer's danger zone. In all pts, emergent thoracotomy was performed, and 5 pts could be saved (mortality 28.6%). As the risk factors, heart injuries, multiple injuries, and gunshot injuries were noticed with mortality of 28.6%, 23.8%, and 37.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Characteristics of central hemodynamics in high-mountain conditions and its changes in penetrating thoracic injuries

It was found that in practically healthy inhabitants of Alpine regions the real oxygen transport is maintained by hyperdynamic regimen of blood circulation, main role in its creation belonging to growth of the stroke volume. The estimation of changing hemodynamics parameters performed by the method of integral rheography is indicated for early detection of patients with risk of the development of pleura empyema after chest wounds.     

Appropriate management of penetrating thoracic stab injuries

Knife-stab chest injuries require immediate adequate treatment according to an established pattern. Depending on the clinical findings, the requisite management is performed: Intubation, central vain catheter, tube drainage according to Bülau, thoracotomy. Stabbing weapons should be removed not before admission to a thoracic surgical clinic ready for immediate operation. One of our cases shows that schematic procedure enables adequate "minimal therapy" in spite of dramatic circumstances.     

Diagnosis and surgical tactics in injuries of the pancreas

Results of the treatment of 49 patients with injuries of the pancreas are analyzed. Lethality was 36.2%. Laparocentesis, laparoscopy and determination of enzymes in the abdominal cavity were used for diagnosis. Early operative interventions gave less amount of complications and better results of treatment.     

The role of diagnostic VATS in penetrating thoracic injuries

Background  

Penetrating chest injuries account for 1–13% of thoracic trauma hospital admissions and most of these are managed with a conservative approach. Nevertheless, 18–30% of cases managed only with tube thoracostomy have residual clotted blood, considered the major risk factor for the development of fibrothorax and empyema. In addition, 4–23% of chest injury patients present persistent pneumothorax and 15–59% present an injury to the diaphragm, which is missed in 30% of cases. In order to make a correct diagnosis, reduce the number of missed injuries, chronic sequelae and late mortality we propose performing surgical exploration of all patients with a penetrating injury of the pleural cavity.     

Characteristics of the diagnosis and surgical treatment of injuries of the duodenum

Specific features of diagnostics and surgical treatment of injuries of the duodenum in 41 patients with open and closed traumas of the abdomen are described. A wide access by means of mobilization of the right colic flexure should be used for the revision of the duodenum. In cases with closed injuries of the duodenum, in addition to maintenance of its reliable decompression, it is necessary to exclude the intestine from the passage of the gastric content. In order to prevent postoperative pancreatitis cholecystostoma should be made.