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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 66-69

Epidemiological pattern of blunt trauma chest in Western India


1 Department of Microbiology, SN Medical College, Jodhpur, Rajasthan, India
2 Department of Surgery, SN Medical College, Jodhpur, Rajasthan, India

Date of Submission29-Apr-2020
Date of Acceptance05-May-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Satya Prakash Jindal
Department of Surgery, SN Medical College, Jodhpur - 342 003, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_27_20

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  Abstract 


Introduction: Chest injuries constitute an important aspect of trauma. Despite high mortality rates, but the majority of patients with thoracic injuries can be managed by a simple intervention like tube thoracostomy. Aims and Objective: The aim of this study is to analyze the epidemiological pattern of chest injury and assess the outcome at our institute. Materials and Methods: This was a prospective observational study done at a tertiary care center of north India from July 2015 to December 2016, including 200 patients. Results: Road traffic accident was the most common cause of chest trauma (61%) followed by fall from height (23%). We observed rib fracture in 78% of patients, surgical emphysema in 31%, hemopneumothorax in 31.5%, hemothorax in 25%, and pneumothorax in 8.5% patients. Twenty-four percent (48/200) patients were managed conservatively, whereas 72.5% (145/200) patients were managed by chest tube drainage. Only seven (3.5%) patients underwent surgical procedures for chest injury in terms of thoracotomy or laparotomy. The mortality rate in our study was 6.5%, whereas 9.5% of patients required ventilator support. Conclusion: In our study, most of the patients were managed conservatively or simply by chest tube drainage. The overall prognosis depends more on associated injuries and morbidity. Associated head injury is the major factor behind need of ventilator and intensive care unit support and led to death in the majority of patients.

Keywords: Chest trauma, chest tube, hemothorax, pneumothorax, thoracotomy, trauma


How to cite this article:
Gupta AK, Sharma AK, Suthar NK, Girija H R, Verma V, Jindal SP. Epidemiological pattern of blunt trauma chest in Western India. Apollo Med 2020;17:66-9

How to cite this URL:
Gupta AK, Sharma AK, Suthar NK, Girija H R, Verma V, Jindal SP. Epidemiological pattern of blunt trauma chest in Western India. Apollo Med [serial online] 2020 [cited 2020 Sep 28];17:66-9. Available from: http://www.apollomedicine.org/text.asp?2020/17/2/66/287086




  Introduction Top


Trauma is the most dreaded problem of present society. The rapid pace of industrialization coupled with an increase in the number of automobiles and vehicular accidents, giving us an increased incidence of trauma. Chest injuries constitute an important aspect of all cases of trauma. In spite of high mortality rates, about 80%–90% of patients with life-threatening thoracic injuries can be managed by a simple intervention like drainage by tube thoracotomy.[1]

Injury statistics of India are definitely different from that of the developed world where most research work is done. The purpose of the present study is to analyze the epidemiological pattern and our experience in dealing with these injuries with reference to management and outcome.

Aims and objective

  1. To analyze the epidemiological pattern of chest injury at our institute
  2. Analyze the outcome of the management of these patients.



  Materials and Methods Top


Study design

This study was done at a tertiary care center of north India from July 2015 to December 2016. This was a prospective observational study to analyze the clinico-epidemiological pattern of chest injury in our settings. We included 200 patients of chest injury who presented to our center during the study period.

Patient information and consent

Patient and their relatives were informed about the details of the study. Written and informed consent was taken.

Data collection technique and tools

Data were recorded during the admission of the patient and followed for 6 weeks after discharge during the visit of the patient in the outpatient clinic or telephonically.

History was noted in detail, including mode of injury, type of injury, and type of weapon if used and Time since injury. Clinical examination was done on the arrival of patient focused on vital parameters. Urgent life-saving interventions were done in patients with life-threatening conditions such as tension pneumothorax and cardiac tamponade in the emergency room before proceed further. Then, a secondary survey was done after the patient had been stabilized, to access the patient completely, and a Head to Toe examination was done to note all injuries and diagnosed with the help of clinical, radiological, and laboratory examination and treated accordingly.

Results of these various managements were noted according to their requirement, morbidity in terms of days of stay to hospital and further fate, the final outcome in terms of discharge from hospital satisfactorily, any complications and death, and follow-up were noted and analyzed.

Data analysis

Statistical analysis was performed using SPSS version 20.0 and R3- SPSS Statistics is a software package used for interactive, or batched, statistical analysis. Long produced by SPSS Inc., it was acquired by IBM in 2009. Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentages. A Chi-square test or Fisher exact test was used for assessing the significance of the categorical variable. A Wilcoxon rank-sum test statistics were used to test the significance of response of different continuous parameters between the groups. For all statistical tests, a value of P < 0.05 will be taken to indicate a significant difference.


  Results Top


We included a total of 200 patients with chest injury presented to our emergency department during the study period. Among them 82.5% (165/200) were male and 17.5% (35/200) were female. Middle age was most affected and 66% (132/200) patients were between the age of 21–50 years. Road traffic accident (RTA) was the most common cause of chest trauma (61%), followed by fall from height (23%). Other less common causes included assault with stick (Lathi) and injury by animals.

The pattern of injury after the complete evaluation is shown in [Table 1]. Rib fracture was seen in 78% of patients; among them 24% (48/156) had exclusive rib fractures and managed conservatively without any surgical intervention. Fourteen patients had flail chest; among them, six patients required ventilator support and eight patients managed conservatively. Surgical emphysema was seen in 62 (31%) patients. After evaluation, 31.5% of patients had hemopneumothorax, 25% patients had hemothorax and 8.5% of patients had isolated pneumothorax, which were managed by putting chest tube instantly.
Table 1: Pattern of injury in chest trauma

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In our study, one patient had the tracheobronchial injury, required thoracotomy and prolonged intubation and ventilator support, but the patient succumbs of his illness. Six patients had a diaphragmatic injury, underwent diaphragm repair. We did not observe any case of vascular or esophageal injury in our study.

Eighty-four (42%) patients had other associated injuries in our study, most common being head injury (26.5%). Five patients had liver injury, four patients had spleen injury and rest have some bony injuries, which were managed accordingly. The associated injury had an adverse effect on prognosis in these patients, and most patients succumbed due to associated head injury.

[Table 2] shows the overall treatment approach in our study. Twenty-four percent (48/200) patients were managed conservatively, except some orthopedic or neurosurgical procedures, while 72.5% (145/200) patients were managed by chest tube drainage only for chest trauma. Only seven (3.5%) patients underwent surgical procedures for trauma in terms of thoracotomy or laparotomy. Among them, one patient underwent thoracotomy for bronchial injury, three patients underwent diaphragmatic repair by thoracotomy approach, and three patients with simultaneous splenic injury underwent splenectomy and diaphragmatic repair by laparotomy. The duration of hospital stay in trauma patients depends upon the severity of the injury. In our study, the duration of hospitalization varied from 1 day to 35 days, but most patients were admitted for around 8–13 days with a mean of 8.51 days.
Table 2: Management approach in patients with chest trauma

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The most common complication was atelectasis of affected lung, which was reported in 6% of patients in our study, followed by empyema and pneumonia in 2.5% of patients. These complications are slightly more in patients treated with the conservative approach, but not statistically significant. The patients, who were operated, required more intensive care than others. Among all, 9.5% (19/200) patients required ventilator support, most patients with polytrauma. In this study, 6.5% (13/200) patients succumbed, most having associated head injury. [Table 3] shows the overall prognosis of chest trauma patients in our study.
Table 3: Outcome and prognosis in chest trauma patients

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In this study, most of the patients were managed conservatively or simply by chest tube insertion. The overall prognosis depends more on associated injuries and morbidity. Chest trauma led to death only in two patients, one with tracheobronchial injury and another one with a massive contusion of the right lung. Associated head injury is the major factor behind need of ventilator and intensive care unit (ICU) support and led to death in the majority of patients.


  Discussion Top


The rapid pace of industrialization coupled with an increase in the number of automobile and vehicular accidents, is giving us an increased incidence of chest trauma. Even after making great advances in medical instrumentation, diagnostic modalities, and improvement in operative technique, chest trauma is taking its toll in the form of mortality, morbidity, and loss of workdays to a significant extent.[2]

In 1992, Galan et al. stated that RTA was the most common cause of chest trauma followed by outdoor falls and accidents due to sports activity. They reported that RTAs lead to 62% of cases of blunt trauma chest.[3] Similarly, in our study, 59.5% of patients were injured due to RTAs. Contrary to the urban area, traffic in villages is much less and most of the trauma spectrum revolves around occupational hazard and more so due to falls, for example, fall from tree, machan, etc., Lathi and stones are commonly used in injuring objects in case of assault in India.[4]

Atri et al. in 2006 studied that among 240 cases of chest trauma, 78.7% were male and remaining 22.3% were female.[5] Similarly, in our study, males are more commonly affected and represent 82.5% of cases. In our study male to female ratio was 4.71:1. The low incidence in females may be due to more confinement to domiciliary work, less outdoor activities, and less driving of vehicle as compared to males. Atri et al. evaluated that majority of people are of 21–50 years of age and mean age was 34.5 years.[5] Similarly, in our study, majority of patients were found to be in 21–50 years of age group (mean age 37.2 years). These are comparable to previous studies. This is important as this is the most active and productive age group.

Diagnosis of chest trauma is simple rather than abdominal and head injuries, but significant factors are time lag between injury and patient presenting to physician and delay in diagnosis and proper management by the emergency medical officer. The mainstay of diagnosis lies with physical examination added with plain X-ray, pleural tap, ultrasonography, and computed tomography scan.[6]

Lungs and pleura are the most susceptible organs to be injured during chest injury. Common injuries include pneumothorax, hemothorax, hemopneumothorax, pulmonary contusion, and lung laceration. Atri et al. studied 240 cases of chest trauma and observed that rib fracture present in 60% of cases. This is followed by surgical emphysema in 37% cases, hemopneumothorax in 27.1% cases, hemothorax in 21.7%, and lung contusion in 10% cases.[5] In our study, similarly, we found that 78% of patients of chest trauma presented with a rib fracture. Surgical emphysema was present in 31% cases; hemopneumothorax in 31.5% of cases and hemothorax in 25% of cases. In our study, isolated pneumothorax was seen in 8.5% of cases and lung contusion in 10% of patients with chest trauma. Flail chest was present in 7% of patients and diaphragmatic injury in 3% cases of trauma chest. Only one case of tracheobronchial injury was seen. We did not report any case of cardiac, vascular, or esophageal injury in this study.

In tension pneumothorax, a one-way communication occurs between the airway and pleural cavity. Air enters in the pleural cavity and progressively accumulates, causing compression of ipsilateral lung and displaces mediastinum to the opposite side. Helling et al. published that tension pneumothorax and cardiac tamponade are clinical diagnosis and should be managed aggressively without waiting for any prior investigation. In our study, we observed six cases of tension pneumothorax, which were managed by immediate chest drain and all were survived.[7]

Al Saigh et al. in 1999 stated that head injury present in 19% cases, abdominal injuries in 12% cases, and long bone fracture in 11% cases.[8] Atri et al. observed that the prevalence of associated injuries was 48.7% cases of chest trauma. Head injury was associated in 35.1% cases, fracture of long bones in 16.4%, spleen rupture in 8.4%, liver injury in 6.8% cases, and pelvic fracture in 7% cases of chest trauma.[5] Similarly, in our study, we found associated extrathoracic injuries in 42% of cases of chest trauma. Head injury was most common among all (26.5%) followed by long bone injury in 12% of cases.

Galan et al. in 1992 reviewed 1696 patients with blunt trauma chest and evaluated that 54% cases were treated conservatively and 38% of cases required tube drainage and 6% patients required thoracotomy.[3] In contrast to the above series in this study, we evaluated that 24% patients with chest trauma are treated conservatively, 72.5% required chest tube drainage. Three percent of patients with chest trauma required thoracotomy. Laparotomy was done in 6% patients due to abdominal and diaphragmatic injuries. Similar results were observed by Cakan et al. in 2001, who reported that 41% of patients underwent tube thoracostomy alone while the majority of patients are treated conservatively, and only 3% required thoracotomy.[9]

Cakan et al. in 2001 evaluated that complication rate in chest trauma is 4.6% and the most frequent complication was atelectasis. Mean hospital stay was 9.6 ± 8.9 days. Similarly, in our study, mean hospital stay was 8.5 days.[9]

Khan et al. in 2009 evaluated that 15% of patients developed complications after chest tube insertion, including empyema, pneumonia, and wound infection. Overall mortality was 8% among which 5 had multiple trauma, 2 had associated head injury and one was with flail chest on ventilatory support. Similarly, in our study, the complication rate was 15% in chest trauma patients. Five percent among them developed wound infection at chest tube insertion site, 5% develop atelectasis, 2.5% develop empyema, and 2.5% develop pneumonia.[10]

Demirhan et al. observed that mortality rate was 6.8%, and the morbidity rate was 3.3% among chest trauma patients in his study. Similarly, in our study, mortality rate was 7.5%. Most of them have multisystem injuries; head injury is the most common associated lethal injury. Again mortality rate was more in older age group patients and observed 30% in older >70 years of age. Early diagnosis and immediate appropriate treatment in thoracic trauma increase survival.[11]

In our study, 9.5% of chest trauma required mechanical ventilation in the form of endotracheal intubation and ventilatory support and almost all of them had flail chest or associated head injury. Nine percent patients required only O2 inhalation and improved thereafter. ICU care was needed in 11.5% of patients in terms of ventilator support and other patients required close observation.

Poor prognostic factors in chest trauma patients include;

  • Multiple organ injuries
  • Associated head injury
  • Increased time interval between injury and hospitalization
  • Delayed diagnosis and treatment.



  Conclusion Top


This study concluded that RTAs are the most common cause of chest trauma accounting for 59.5% cases. Male of productive age group (21–50 years) are most susceptible to trauma. Rib fracture is the most common injury in chest trauma and present in 78% cases followed by hemothorax and pneumothorax. The mortality rate was 7.5% in our study. Majority of them are older patients and have multisystem injuries. Most patients can be treated conservatively or simply by tube thoracostomy. Thoracotomy was required only in 3% of cases of trauma chest in our study. Thus, mortality can be decreased significantly, if patient reaches at tertiary center earliest and appropriate treatment started.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Farooq U, Raza W, Zia N, Hanif M, Khan MM. Classification and management of chest trauma. J Coll Physicians Surg Pak 2006;16:101-3.  Back to cited text no. 1
    
2.
Livingston DH, Richardson JD. Pulmonary disability after severe blunt chest trauma. J Trauma 1990;30:562-7.  Back to cited text no. 2
    
3.
Galan G, Peñalver JC, París F, Caffarena JM Jr., Blasco E, Borro JM, et al. Blunt chest injuries in 1696 patients. Eur J Cardiothorac Surg 1992;6:284-7.  Back to cited text no. 3
    
4.
Marya SK, Singla SL. Management of chest injuries by a general surgeon. Indian J Surg 1987;49:235-8.  Back to cited text no. 4
    
5.
Atri M, Singh G, Kohli A. Chest trauma in Jammu region as institutional study. Indian J Thoracic Cardiovasc Surg 2006;22:219-22.  Back to cited text no. 5
    
6.
Locicerco J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-6.  Back to cited text no. 6
    
7.
Helling TS, Gyles NR 3rd, Eisenstein CL, Soracco CA. Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy. J Trauma 1989;29:1367-70.  Back to cited text no. 7
    
8.
Al Saigh A, Fiaz M, Abdulla R. Chest trauma in children: A local experience. Ann Saudi Med 1999;19:106-9.  Back to cited text no. 8
    
9.
Cakan A, Yuncu G, Olgaç G, Alar T, Sevinç S, Ors Kaya S,et al. Thoracic trauma: Analysis of 987 cases. Ulus Travma Derg 2001;7:236-41.  Back to cited text no. 9
    
10.
Khan MLZ, Haider J, Alam SN, Jawaid M, Malik KA. Chest Trauma Management: Good outcomes possible in a general surgical unit. Pak J Med Sci 2009;25:217-21.  Back to cited text no. 10
    
11.
Demirhan R, Ohan B, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: A 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450-3.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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