Vol 41 # 3 September 2009 - Kma.org.kw

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Blunt and Penetrating Thoracic Trauma: Management Strategy and Short-Term Outcome
September 2009
Fig. 2: Posteroanterior chest radiograph of a patient stabbed with a
metal bar into his right hemithorax
for bleeding, three patients (2%) had postoperative
atelectasis requiring bronchoscopy and suction,
two patients (1%) required prolonged mechanical
ventilation and two patients (1%) had prolonged air
leak that was treated conservatively.
DISCUSSION
Penetrating and blunt thoracic injuries frequently
cause serious injuries to pulmonary, cardiac and
thoracic vascular structures. Most chest trauma
victims can be successfully managed without
operation [3,7,8] . Penetrating injuries to the chest in a
civilian practice result mainly from stab injuries or
gunshot wounds [8] (Fig. 2, 3). In patients who require
operative intervention, complex investigations are
usually not needed to arrive at a diagnosis and
prompt surgery is all that is needed. Delaying urgent
surgery and ongoing blood loss are associated with
the occurrence of ARDS that will lead to a higher
mortality [8] . In this article, we review our experience
with blunt and penetrating chest injuries in patients
who underwent surgical interventions with emphasis
on surgical approaches and postoperative outcome.
Our preoperative management strategies include
draining pleural collection of blood and air, aggressive
resuscitation and when indicated, urgent surgery
without resorting to unnecessary investigations.
Most patients sustaining blunt thoracic injuries
reaching alive in the emergency department can be
managed non-operatively [1-3] . Diagnosis of blunt
injuries may be more difficult and require additional
investigations such as CT scan. Delayed diagnosis
usually reflect concealed injuries such as those
depicted in Table 3 and these in turn are associated
with delayed operative approach due to failure to
recognize them at an early stage. Massive air leak
usually denotes tracheo-bronchial injury or massive
pulmonary laceration. Early diagnosis and surgical
intervention can improve the prognosis [1-3,6] . The
diagnosis of major airway injury depends first, on
Fig. 3: Posteroanterior chest radiograph of a patient with penetrating
injury (metal screw) into his anterior mediastinum
physical examination and then, on findings on chest
radiography. Accurate interpretation of the chest
radiograph is essential in the diagnosis of bronchial
injury. Subcutaneous emphysema and pneumothorax
was present in 10 patients in this series. Liberal use
of bronchoscopy is important to make the diagnosis.
Majority of these injuries can be repaired primarily.
We tried to avoid lung resections in patients with lung
lacerations. Resections are only resorted to when there
is a complex bronchial injury beyond repair. This is to
avoid subsequent high morbidity and mortality [3, 6] .
Thoracotomy was the principal procedure used in
our series, being done in 87% of cases (Table 1). This
is in contrast to video-assisted thoracoscopy (VATS)
which was done in 8% of cases. VATS can be used
safely in hemodynamically stable patients with no
cardiovascular or great vessel injury, sparing many
patients the pain and morbidity associated with a
thoracotomy incision [7] . In addition, VATS can allow
visualization of all lung fields. Its use in our series was
low due to the emergency nature of our patients. VATS
use tends to be reserved for hemodynamically stable
patients provided adequate equipment is available. This
was not the case since our series encompassed patients
operated upon in six different general hospitals, most
of which lacked appropriate instruments required for
VATS. The use of other techniques such as sternotomy or
thoraco-abdominal approach was only limited to some
cases (Table 1) as dictated by the initial presentation and
assessment of these individualized cases.
Delayed surgical intervention can result in a high
mortality. In our series, overall mortality was only
4% (7 patients), three of which died intra-operatively
from cardiac arrest and four had developed ARDS
postoperatively. Overall morbidity in this series occurred
in 10 patients (7%). Only three patients required reexploration
for bleeding. The remainder were due to
postoperative atelectasis and prolonged ventilation or
prolonged air leak that settled conservatively. Certainly,
the complexity of most of these cases necessitates