Symposium on Trauma

Nonpenetrating Thoracic Injuries

Robert F. Wilson, MD.,* Charles Murray, MD.,t and David R. Antonenko, MD.!

Chest injuries are directly responsible for over 25 per cent of the 50,000 to 60,000 fatalities that result annually from automobile accidents and contribute significantly to another 25 per cent of these deaths.4.6 In most hospitals about two-thirds of the severe nonpenetrating thoracic injuries are due to traffic accidents. In trauma centers such as Detroit General Hospital, however, the frequency and severity of nonautomobile trauma is increased to about 50 per cent (Table 1). In addition to this increase in numbers of thoracic injuries, more rapid transportation by trained ambulance personnel is bringing many critically injured patients to the Emergency Department who previously would have died at the scene of the accident or en route to the hospital. Pathophysiology The basic pathologic mechanism involved in high speed accidents is the abrupt application of a shearing force to fixed and nonfixed contiguous intrathoracic structures as the patient rapidly decelerates. The mechanism underlying low speed accidents is the application of a more localized crushing type of injury to the thorax. The consequences of shearing and crushing associated with nonpenetrating thoracic trauma are less commonly seen in patients under the age of 7 years, due to the greater elasticity of the child's thorax. Initial Resuscitation Adequate ventilation must be provided immediately, particularly if there is any impairment of cardiovascular function. Of 340 patients admitted to Detroit General Hospital with nonpenetrating chest trauma

From the Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan *Professor of Surgery tClinical Assistant Professor of Surgery tAssociate Professor of Surgery, University of Alberta Faculty of Medicine, Edmonton, Alberta, Canada; Formerly, Instructor of Surgery, Wayne State University School of Medicine

Surgical Clinics of North America- Vol. 57, No.1, February 1977

17

18

R. F.

WILSON,

C.

MURRAY, AND

D. R.

ANTONENKO

Table 1. Etiology of Blunt Chest Trauma, Detroit General Hospital, 1974-1975 PER CENT

NUMBER

Falls Auto Beatings Motorcycle Other Unknown TOTAL

PATffiNTS

DEATHS

MORTALITY RATE

106 119 91 6 5 13

9 19 3

8.5 16.0 3.3 16.7

2

15.4

340

34

10.0

during 1974 and 1975, 19 (5.6 per cent) had both shock and acute respiratory distress when first seen in the Emergency Department and 16 of these 19 (84.2 per cent) died. If the patient is not breathing adequately, airway obstruction must be ruled out by checking for foreign bodies, such as dentures or vomitus in the upper airway, and for mandibular or laryngeal injuries. Where possible the airway should be restored immediately. If adequacy of the airway remains questionable, an endotracheal tube should be inserted. If an endotracheal tube cannot be inserted, a coniotomy (cricothyroidotomy) or tracheostomy is required. Persistent inadequate ventilation following intubation or tracheostomy is frequently the result of a hemothorax, pneumothorax, or hemopneumothorax which is best managed by chest tube(s) attached to waterseal drainage and 10 to 20 cm H 2 0 suction. If ventilation is still inadequate or questionable, ventilator assistance should be provided. Initially 40 to 70 per cent oxygen is usually adequate, but if cardiovascular function is impaired, 100 per cent oxygen should be administered. It must be emphasized that the great majority of patients with blunt chest injuries can be treated without major surgery. Emergency thoracotomy is needed in less than 5 per cent of patients with blunt thoracic

Table 2. Blunt Chest Injuries at Detroit General Hospital (1974-1975) With Frequency and Severity of Associated Extrathoracic Injuries* EXTRATHORACIC INJURffiS

THORACIC INJURIES

None

Mild

Moderate

Severe

Mild Moderate Severe

6 114(1) 13(4)

6 22(0) 11(1)

6