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

September 2009
KUWAIT MEDICAL JOURNAL 229
management by a dedicated thoracic surgeon. The
achievement of low postoperative mortality was
the direct result of prompt diagnosis and operative
intervention as 86% of the patients in our series had
surgery performed within two hours of presentation.
In the emergency department, chest radiography
was the most commonly used investigation [1,2,8,9] .
Fiber-optic bronchoscopy was performed when
airway injuries were suspected in the presence of
persistent pleural leak [1,2] . Echocardiography was done
in patients suspected of valve injury or pump failure
due to cardiac tamponade [10] . CT of the chest is of great
value in aiding the diagnosis of blunt trauma [11] .
Our criteria for exploration is somewhat more
aggressive than the criteria suggested by other authors [1,2]
because we found intra- operatively that blood collection
in the pleural cavity varied between 300 ml to 3000 ml
in all bleeding patients with good functioning and well
positioned chest tube. If the decision to perform surgery
is based on the bleeding volume, then an unacceptable
delay in the treatment will result.
Penetrating injuries under the nipple anteriorly and
scapula posteriorly can involve the abdominal cavity
and abdominal examination can be unreliable in the
presence of great thoracic injury [9,10] . It has been stated
that gunshot wounds of the thorax can involve the
abdominal cavity in 30-40% of cases [9] .
We advocate preservation of thoraco-abdominal
barrier to prevent thoracic contamination and to preserve
the diaphragmatic function. We had to resort to thoracoabdominal
approach in two patients only and they had
blunt chest trauma. Most patients with penetrating
injuries had primary repair using techniques specific
to the injury except for one patient who underwent
cardiopulmonary bypass and mitral valve replacement
after the primary surgery.
CONCLUSION
Our results indicate that all thoracic injuries that
required urgent surgical intervention should be
managed by a thoracic surgeon rather than a trauma
or general surgeon because of the complexity of the
injuries involved. In the timely management of patients
with thoracic injuries undue delay should be avoided.
Our results suggest that early surgery decreased the
morbidity and mortality.
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