|Year : 2018 | Volume
| Issue : 1 | Page : 133-139
Blunt vs. penetrating chest trauma in terms of the outcome in Menoufia University Hospital
Mohamed L Alam El-Din1, Medhat R Nashy2, Mai T Meshhal1
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
|Date of Submission||14-Oct-2016|
|Date of Acceptance||14-Dec-2016|
|Date of Web Publication||14-Jun-2018|
Mai T Meshhal
4b Masaken El-Taawoneat, Al-Galaa Bahry Street, Shebeen El-Kom, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare the different presentations, management, and outcomes of blunt and penetrating chest trauma patients who presented to the Emergency Department of Menoufia University Hospital.
Chest trauma accounts for 10% of trauma admissions and 25–50% of trauma deaths worldwide. Different types and grades of severity of chest trauma along with various associated body injuries result in variable outcomes.
Patients and methods
This prospective study included 100 patients with acute chest trauma who presented to the Emergency Department of Menoufia University Hospitals. All patients were managed according to Advanced Trauma Life Support guidelines in the emergency department, followed up in the Cardiothoracic Surgery Department, or in the ICU according to diagnosed injuries, treatments, and outcomes. Data were described in percentages.
Out of 100 patients, 72 patients had blunt chest trauma and 28 patients had penetrating trauma. The male: female ratio was 7: 1 in blunt trauma patients and 13: 1 in penetrating trauma group. The most common mode of blunt trauma was motor vehicle accident (76.4%), whereas stab wound was the most common cause (67.9%) of penetrating trauma. Tube thoracostomy was the most common intervention in blunt and penetrating chest trauma (P = 0.013). No mortality was found in penetrating trauma patients, whereas five blunt trauma patients died, mortality rate 6.9%; four of these deaths were associated with traumatic brain injury.
Thoracic trauma is an important cause of hospitalization, morbidity, and mortality. The incidence of chest trauma was higher in males than females. The ICU stay was significantly longer among patients with blunt chest trauma than penetrating trauma.
Keywords: blunt chest trauma, cardiothoracic trauma, penetrating chest trauma
|How to cite this article:|
Alam El-Din ML, Nashy MR, Meshhal MT. Blunt vs. penetrating chest trauma in terms of the outcome in Menoufia University Hospital. Menoufia Med J 2018;31:133-9
|How to cite this URL:|
Alam El-Din ML, Nashy MR, Meshhal MT. Blunt vs. penetrating chest trauma in terms of the outcome in Menoufia University Hospital. Menoufia Med J [serial online] 2018 [cited 2018 Aug 17];31:133-9. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/133/234225
| Introduction|| |
Thoracic trauma is a significant cause of morbidity and mortality in both adults and children. It is a leading cause of death in 25% of multiple trauma patients and, when associated with other injuries, the percentage increases to reach 50% . Irrespective of the mechanism, the main consequences of thoracic trauma are combined effects on both respiratory and cardiovascular functions, leading to hypoxia, hypovolemia, and reduced cardiac output through direct effects on the thoracic organs .
Only 10–15% of patients with blunt trauma and 15–30% of those with penetrating trauma require surgery. The rest can be treated successfully in the emergency department through the application of fundamental principles of initial trauma management and interventions such as intubation, ventilation, or intercostal tube drainage within the scope of practice of emergency physicians. As thoracic trauma impacts directly on the heart and lungs, these two organs are more integral to the provision of oxygenation and perfusion. Successful management of thoracic trauma depends mainly on effective prioritization of resuscitation through the Airway Breathing Circulation principles with rapid detection and treatment of life threatening injuries .
| Aim|| |
The aim of this work is to study the different presentations, managements, and outcomes of chest trauma patients in populations of different ages, comparing both blunt and penetrating chest trauma, who presented to the Emergency Department of Menoufia University Hospitals.
| Patients and Methods|| |
After the approval of Menoufia Ethics Committee was obtained for the study, this prospective study was carried on 100 patients who presented to the Emergency Department of Menoufia University Hospital; 72 of these patients had blunt chest trauma and 28 patients had penetrating chest trauma. Their ages ranged between 1.5 and 70 years.
They were classified into the following groups according to the mode of trauma: blunt chest trauma group, which included 72 patients with blunt chest trauma. Totally, 63 (87.5%) were males and nine (12.5%) were females. The male: female ratio was 7: 1, mean age 30.7 ± 17.6 years. The penetrating chest trauma group included 28 patients with penetrating chest trauma; 26 (92.9%) were males and two (7.1%) were females. The male:female ratio was 13:1, mean age 30.1 ± 12.8 years.
All patients were managed according to Advanced Trauma Life Support guidelines by primary and secondary survey, and each patient was subjected to a full assessment of history, thorough clinical examination, and laboratory and radiological investigations. Chest computed tomography was performed in cases of chest radiograph opacity, nonconclusive chest radiograph, pericordial region injuries, patients in whom erect chest radiograph could not be performed (hemodynamically unstable and unconscious patients), and pediatric trauma. Transthoracic Echocardiography was done in hemodynamically unstable patients with no obvious cause, positive ECG findings, and penetrating injury in the precordial region. Patients who were admitted were followed up for length of hospital stay (LOS) either in the ward or in the ICU, and type of treatment administered was either surgical or conservative. Surgical intervention was in the form of intercostal tube insertion, which was performed by an intrapleural insertion of a plastic drain through an incision at the fifth intercostal space or by chest exploration through a posterolateral thoracotomy incision extending from the midclavicular line at the fifth rib level till the inferior angle of the scapula cutting skin, latissmus dorsi, and serratus anterior muscles. The thoracic cavity was exposed by opening in intercostals muscles and application of a chest retractor, and repair of the underlying pathology as a diaphragmatic tear was performed [Figure 1].
The data collected were tabulated and analyzed using the statistical package for the social science software (SPSS, version 20 on an IBM compatible computer; SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean and SD and analyzed using a t-test for comparison between two groups of normally distributed variables, whereas for comparison between two groups of non-normally distributed variables, the Mann–Whitney test was used. Qualitative data were expressed as number and percentage and analyzed using a χ2-test, and for 2 × 2 table and fisher's exact test was applied if expected number of one cell was less than 5. Spearman's correlation was used for non-normally distributed quantitative variables or when one of the variables was qualitative.
| Results|| |
There was no statistically significant difference between both blunt and penetrating chest trauma groups in age and sex [Table 1].
Motor vehicle accident (MVA) was the leading cause of blunt trauma (76.4%), followed by localized chest trauma (12.5%) and falling from a height (11.1%) [Table 2], [Figure 2]. Stab chest was the main cause of penetrating trauma (67.9%), followed by shot gun (17.8%) and gunshot (14.3%) [Table 3], [Figure 3].
A significant difference was detected between blunt and penetrating trauma patients in the diagnosed injuries. In the blunt chest trauma group, 26 (36.1%) patients (P = 0.001) had multiple rib fractures and nine (12.5%) patients (P = 0.05) had flail chest, whereas this diagnosis was not made among patients with penetrating trauma [Table 4] and [Table 5].
A significant difference was detected between both groups in intercostal tube insertion (P = 0.013). Intercostal Tube (ICT) insertion was inserted into 23 (82.1%) patients with penetrating trauma compared with 40 (55.6%) patients with blunt trauma [Table 6].
A significant difference was detected between both groups in ward admission (P = 0.016). All (100%) penetrating trauma patients were admitted in the cardiothoracic ward compared with 81.9% of blunt trauma patients, with no significant difference in the in-ward duration of stay [Table 7].
|Table 7: ICU and ward admissions in blunt trauma comparable with penetrating trauma|
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A significant difference was detected between both groups in ICU admission (P = 0.013). Only 17.9% of penetrating trauma patients were admitted in the ICU compared with 44.4% of blunt trauma patients. A highly significant difference was detected between both groups in ICU stay (P = 0.009) as, in the blunt trauma group, ICU stay was 2.74 ± 5.59 days compared with 0.36 ± 0.91 days recorded for the penetrating trauma group [Table 7].
No mortalities were recorded in the penetrating chest trauma group, whereas in the blunt trauma group, five (6.9%) patients died, 59 (81.9%) were discharged after treatment, and eight (11.1%) were not admitted as no admission was required [Table 8], [Figure 4]. In terms of mortality, four patients had traumatic brain injury and one had massive bilateral lung contusion.
|Table 8: Outcome of the studied group with blunt trauma in comparison with the group with penetrating trauma|
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|Figure 4: Outcome of the studied group with blunt trauma in comparison with the group with penetrating trauma.|
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| Discussion|| |
Thoracic trauma is a significant cause of morbidity and mortality in both adults and children. It is a leading cause of death in 25% of multiple trauma patients and, when associated with other injuries, the percentage increase to reach 50% .
In this study, 72 of 100 patients had blunt chest trauma, whereas 28 patients had penetrating chest injuries. This is in agreement with Ulutas et al. , who studied 996 patients; 761 of these patients had blunt trauma and 235 had penetrating trauma. However, the Khorsandi et al.  study showed more prevalent penetrating chest trauma than blunt chest trauma in the patients studied.
The number of males as higher than the number of females in our study. In the blunt trauma group, the male:female ratio was 7: 1 and in the penetrating trauma group, male:female ratio was 13: 1. These results are in agreement with the results of Ekpe and Eyo , who studied 149 patients with chest trauma; 121 were males and 28 were females, with a male: female ratio of 4: 1.
In the present study, no significant difference was detected in age. In the blunt chest trauma group, the mean age of the patients was 30.7 ± 17.6 years, whereas in the penetrating trauma group, the mean age of the patients was 30.1 ± 12.8 years. These results are in agreement with Saaiq and Shah , who studied 143 patients and reported that the mean age of the patients was 36.53 ± 14.43 years.
In terms of the mode of trauma, in the blunt chest trauma group, MVA (all traffic-related accidents) was the most common cause, 55 (76.4%) patients, which is in agreement with El-Menyar et al. , with traffic-related injuries (63%) being more common among blunt trauma patients. Saaiq and Shah  also reported similar results; road traffic accidents were the leading cause of thoracic trauma, with motorbikes being the most frequently involved vehicles, accounting for 46% of them.
Also, El Wakeel et al. , who studied the role of computed tomography in the detection of blunt chest trauma complication, obtained results that were in agreement with our study, reporting that the most common cause of chest trauma was MVAs, which was reported in 80 (80%) patients.
In terms of penetrating trauma in this study, stab wounds were the most common mode of injury in 19 (67.9%) patients, which is in agreement with Berg et al. , who reported that 61 (69.3%) patients of their study group sustained stab wound. In agreement with our study, Yazici et al.  studied penetrating chest injuries in Ankara and found that stab wounds were the most frequent mode of injury, involving 89 (89.9%) cases; the rest of the 10 (10.1%) patients had gunshot wounds. In contrast to our study, Khan and Bilal  studied 120 patients with penetrating chest trauma and found that gunshot wounds were more common than stab wounds as 105 patients had missile injury, four patients had stab wound, and one patient had steel bar injury.
MVAs are the leading cause of trauma, which may have many possible explanations. Quistberg et al.  reported that badly constructed roads are involved causes because of the high density of vehicle traffic, limited walking paths and spaces, street vendors blocking access, poor-quality walking surfaces, and visibility reduced by vehicle parking. Another explanation could be cannabis intake by drivers; Asbridge et al.  reported that acute cannabis consumption is associated with an increased risk of a motor vehicle crash, especially fatal collisions. Huisingh et al.  provided an important explanation in terms of specific age groups of drivers, concluding that visual field area impairment in older drivers increase the rate of motor vehicle collision.
Huber et al.  studied poor outcome predictors after significant chest trauma in multiply injured patients; they found rib fractures in 11 475 (51%) patients including 35% rib fractures (7794 patients), 16% flail chest (3681 patients), in agreement with the present study. Among 37 (51.4%) patients, 36.1% had multiple rib fractures, 12.5% had flail chest, and 2.8% single rib fractures.
Kessel et al.  reported that mortality of rib fracture patients was mostly affected by the presence of extra thoracic injuries. This result is in contrast to Saaiq and Shah , who found four cases of traumatic diaphragmatic rupture; all were because of blunt trauma. Associated injuries in the Ekpe and Eyo  study were found 25.5% of patients and were positively correlated with mortality (P = 0.0003).
In the present study, only the blunt chest trauma group had mortality; five (6.9%) patients died and four of these patients had associated traumatic brain injury in agreement with El-Menyar et al.'s  study, in which patients who died had a higher rate of associated head injury (73 vs. 33%), indicating that the main independent predictors for mortality in traumatic chest injury are associated head injury.
Ekpe and Eyo  studied determinants of mortality in chest trauma patients and reported results that were almost similar to those of our study, describing an overall mortality rate 5.4% in comparison with 6.9% in our study, and found that Associated extra thoracic organ injury, delayed presentation with injury to presentation interval longer than 24 h, and severe chest injury as characterized by bilateral chest involvement correlated positively with mortality.
A systematic review and meta-analysis to determine the risk factors that predict mortality in patients with blunt chest wall trauma carried out by Battle et al.  found that the risk factors for mortality in patients sustaining blunt chest trauma were patient age of 65 years or older, three or more rib fractures, and the presence of pre-existing disease, specifically cardiopulmonary disease. The development of pneumonia after injury was also a significant risk factor for mortality in patients with blunt chest trauma.
In nearly similar results to our study having no mortality in penetrating trauma, Yazici et al.  carried out a retrospective study of 99 penetrating trauma patients over 4 years, in which only one (1%) patient died, caused by massive hemorrhage before thoracotomy was performed.
The absence of mortality in penetrating trauma patients in our study may be explained by the presence of emergency residents, who rapidly managed any critically ill patients according to Advanced Trauma Life Support guidelines for management and resuscitation, along with a rapid response to consultation and early surgical interventions by the cardiothoracic team.
One of the main factors for survival is rapid arrival to the hospital within the golden hour; this is defined as the first 60 min after the occurrence of a major multisystem trauma. It is widely believed that the victims' chances of survival increase considerably when they receive specialized trauma care within this 'Golden Hour'. The availability of efficient ambulance services is mandatory to manage patients in the golden hour .
The LOS is an important measure of morbidity; also, estimates of LOS are important for financial reasons and accurate early estimates facilitate better financial planning by the payers . LOS was almost similar in blunt and penetrating trauma, ranging from 0 to 25 and 1 to 30 days, respectively, in agreement with Khorsandi et al. , who found no significant difference in the LOS between patients who had blunt trauma and those who sustained penetrating trauma.
In the present study, blunt trauma patients more significantly required ICU admission (44.4%) more than penetrating trauma (17.9%). Length of ICU stay was significantly longer in blunt trauma than penetrating trauma patients, ranging from 0 to 27 days in blunt trauma patients and 0 to 4 days in penetrating trauma patients. Khorsandi et al.  performed an 11-year review of outcomes of major cardiothoracic trauma in the North West of England and found no significant difference in ICU stay between patients who suffered blunt trauma and those who sustained penetrating trauma; this was not in agreement with our study.
Lema et al.'s  prospective study, which was carried out at the Accident and Emergency Department and surgical wards of Bugando Medical Centre over a six-month period, found higher LOS than our study, and ranged from 1 to 120 days in comparison with that of the blunt trauma group in our study of 0 to 25 days and the penetrating trauma group of 0 to 30 days. Lema et al.  also reported that associated injuries, type of injury (rib fractures, hemothorax), and trauma scores were found to be significant predictors of the LOS.
According to Lema et al. , 13 (8.7%) patients were admitted to the ICU, which is a lower number than that in our study for both blunt trauma (44.4%) and penetrating trauma (17.9%). Lema et al.  also reported that the need for ICU admission was found to be associated significantly with mortality (P = 0.021).
| Conclusion|| |
The incidence of chest trauma was higher in males than females. The incidence of blunt chest trauma was higher than penetrating chest trauma. Length of stay in the ICU was significantly longer in the blunt chest trauma group of patients than the penetrating trauma group. No mortality was found among the penetrating chest trauma patients. Most mortality cases in blunt chest tauma was associated with traumatic brain injury.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]