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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 8  |  Page : 1247-1251

Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry


1 Department of Surgery, Division of Trauma Surgery/Accident and Emergency Unit, Jos, Nigeria
2 Department of Surgery, Division of Cardiothoracic Surgery, Jos University Teaching Hospital, Jos, Nigeria

Date of Submission24-Feb-2021
Date of Acceptance11-May-2021
Date of Web Publication14-Aug-2021

Correspondence Address:
Dr. S D Peter
Department of Surgery, Division of Trauma Surgery/Accident and Emergency Unit, Jos University Teaching Hospital, Jos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_92_21

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   Abstract 


Background: Chest injury remains a major source of morbidity and mortality in trauma as approximately two-thirds of all severe traumas involve the chest. Objective: To determine the changes in the profile management and outcome of severe chest injury in Jos University Teaching Hospital, Jos, Nigeria. Materials and Methods: This is an analysis of the Trauma Registry of Jos University Teaching Hospital—a prospectively gathered database. Patients' entries with severe chest injuries for 7 years, from January 2012 to December 2018, were entered into a database and analyzed using the Epi Info Statistical Software, using simple statistics. Results: In all, 162 patients presented with severe chest injury over a 7-year period, of whom 78 (48.1%) had polytrauma, while 84 (51.9%) had isolated chest injury. There were 139 males and 23 females, giving male: female ratio of 6:1. Over 95 (58.6%) of them were between 20 and 39 years. Blunt injury was predominant, constituting 66.7%. Motor vehicular crash was the most common mechanism of injury constituting 87 (53.7%), while gunshot injuries were responsible for 34 (21%). In managing these severe chest injuries, 146 (90%) of the patients had closed-chest tube thoracostomy as the definitive treatment, while 16 (9.9%) had thoracotomy. The mean and median duration of hospital stay was 13.3 and 10 days, respectively. The commonest complication was wound infection in 8 (4.9%) patients and a mortality of 5.9%. Conclusion: Blunt chest injury remains the commonest mechanism of chest injury but with an increasing proportion of penetrating injuries affecting predominantly young males. Most severe chest injury patients survive with simple interventions of resuscitation, and closed-chest tube thoracostomy for definitive treatment.

Keywords: Jos University Teaching Hospital, severe chest injury, trauma registry


How to cite this article:
Peter S D, Ozoilo K N, Isichei M W, Ale F, Njem J M, Ojo E, Misauno M A, Ugwu B T. Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry. Niger J Clin Pract 2021;24:1247-51

How to cite this URL:
Peter S D, Ozoilo K N, Isichei M W, Ale F, Njem J M, Ojo E, Misauno M A, Ugwu B T. Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry. Niger J Clin Pract [serial online] 2021 [cited 2022 Jan 25];24:1247-51. Available from: https://www.njcponline.com/text.asp?2021/24/8/1247/323871




   Introduction Top


Trauma is a leading cause of both morbidity and mortality worldwide.[1],[2] It is projected to be the third leading cause of death and disability by the year 2020 and the leading cause of disability-adjusted life years (DALYs).[3] The predominant cause of trauma is vehicular collisions and developing countries, despite having a lower volume of vehicular traffic, have a higher burden of trauma given the poorly regulated traffic safety and weak health systems. It is therefore a problem that is likely to increase in magnitude for low-income nations in time to come.

The chest being almost one-fourth of the total body mass is often subjected to injury during trauma from any etiology such that approximately two-thirds of all severe traumas involve the chest.[4] Chest injury directly accounts for 25% of trauma deaths and contributes indirectly to another 50% such that it contributes overall to 75% of trauma deaths.[5]

Chest injuries are particularly severe because they could involve the airways, interfere with ventilation, or destabilize circulation. These injuries could involve either the chest wall or its contents, presenting either as collections in the pleural cavity, lung parenchymal injury, pericardial collection, or injuries to intrathoracic visceral structures or major vessels. They may also involve the upper abdominal organs like the liver and gallbladder on the right, and the fundus of the stomach and spleen on the left. They may be blunt or penetrating or a combination of both. A previous study had described the pattern and outcome of management of severe chest injuries in our institution—[6] a severe or significant chest injury being any injury involving the chest, with an injury severity score (ISS) greater than 15.[7] Over a decade later with changing demographics of trauma due to several sectarian crises and resulting in increasing proliferation of small arms and light weapons, we sought to examine the current characteristics of chest injury presenting to our institution over a period of 7 years.


   Materials and Methods Top


This is an analysis of the Trauma Registry of the Jos University Teaching Hospital which is a prospectively gathered database. All patients presenting with injuries which alone or in combination require admission were recruited into the Registry at the point of presentation in the accident and emergency and followed-up until discharge or death.

The initial management of the patients followed the Advance Trauma Life Support (ATLS) protocol, and definitive treatment was as dictated by the nature of the specific injuries. Patient entries from January 2012 to December 2018 were analyzed.

All patient data were collected on a two-page trauma datasheet and updated until discharge or death. Information collected included patient demographics, description of injury, and management as well as the outcome of care. The data were then transcribed into an Epi Info database and analyzed with the Epi Info 3.4.1 Statistical Software using simple statistics. Informed consent was obtained from the patients, and ethical approval obtained from the hospital ethics committee 26-April-2018.


   Results Top


A total of 162 patients presented with significant chest injury out of a total of 9,447 trauma patients admitted through the accident and emergency over the 7-year period. This indicates an average of 23 patients per year with severe chest injuries. The demographic characteristics of the patients are shown in [Table 1] and [Table 2], and [Figure 1]. About 139 (85.8%) were males while 23 (14.2%) were females [Figure 2], giving a male: female ratio of 6:1; 59 (36.4%) of them were between the ages of 20 and 29 years and 22.2% between 30 and 39 years [Figure 1], accounting for the highest proportion. The type of injury was predominantly blunt injury (66.7%) as shown in [Table 3] and [Figure 3], with road traffic accidents (RTA) accounting for 53.7%. Gunshot wounds accounted for 21.0% [Table 4]; 78 patients (48%) had polytrauma while the remaining had isolated chest injuries; 146 of the patients (90.1%) had closed-chest tube thoracostomy alone as definitive treatment for their chest injuries while 16 (9.9%) of them required thoracotomy with empyema being the commonest indicator for the thoracotomy [Table 5]. Of the 16 patients that had thoracostomies, 6 were for blunt injuries, while 10 were for penetrating chest injuries. Twenty-six patients (16%) were managed in the intensive care unit. The mean and median duration of hospital stay was 13.3 and 10 days, respectively. The commonest complication is wound infection as shown in [Table 6], and the mortality rate is 5.9%.
Figure 1: Bar chart showing age distribution of severe chest injury

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Figure 2: Sex distribution

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Figure 3: Mechanism of injury

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Table 1: Age distribution

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Table 2: Sex distribution

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Table 3: Mechanism of injury

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Table 4: Etiology

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Table 5: Indications for thoracotomy

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Table 6: Complications of chest injury

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   Discussion Top


Chest injury is a common occurrence and poses a significant challenge in the management of trauma. Our study shows a slight decline from the average of 28 cases a year found earlier between January 1999 and December 2005 by Misauno et al.[6] at the same institution to 23.[6] The male preponderance is in keeping with the male pattern of predominance in trauma generally and was in line with the findings of other studies.[3],[4],[8],[9] Ninety-five (58.6%) patients were between the ages of 20 and 39 years. This is roughly in keeping with Misauno's earlier finding and similar to that of most other authors.[10],[11],[12] This supports the assertion that trauma is a disease of predominantly young adult males.

Although a majority (66.7%) was from blunt injuries, the proportion of penetrating injuries (33.3%) is increasing. This demonstrates a shift in the mechanism of trauma as it can be adduced from the earlier study that blunt injuries predominated while penetrating injuries were uncommon. A majority of chest injury is still from RTA, the proportion has however fallen to 54.3% relative to the 70.7% reported 13 years earlier.[6] Similarly, gunshot injuries which did not feature prominently in the earlier report from this institution[6] currently account for 21.6% in this present report. Findings from other studies in developed societies vary significantly but our environment has previously been dominated by blunt injuries.[5],[13],[14],[15],[16],[17] This is fast changing as gunshot injury is increasing in proportion compared to previous studies both in this center and the sub-region,[6] probably because of increasing amounts of light weapons in the civilian populace[18],[19],[20] and multiple ethnoreligious crises.[19] One reason for this transition may be connected to the fact that our city has witnessed several sectarian crises since the publication of the previous study with a steady proliferation of small weapons and light arms.[21],[22],[23],[24],[25],[26]

Closed-chest tube thoracostomy with underwater seal drainage was sufficient definitive treatment for chest injuries in 89.5% of the patients. This is in keeping with other studies which show that over 85% of chest injuries are amenable to simple measures such as airway maintenance, and at the most, a chest tube insertion.[4],[5],[6],[7] Majority of chest-injured patients present with rib fractures, pleural collections, or pulmonary parenchymal contusion. These are amenable to simple resuscitative measures. Only infrequently does the patient with severe chest injury require a formal thoracotomy as may be seen in massive hemothorax (defined as more than 1,500 mL of blood at initial insertion of chest tube or a continuous yield of more than 200–300 mL of blood from the chest tube over 2–3 hours). These usually result from major intrathoracic vascular injuries or other visceral injuries such as ruptured esophagus or tracheobronchial injury. Most of the patients in this study presented with either simple pneumothorax or hemothorax. Other indications for thoracotomy in chest injury include traumatic hemopericardium; loss of chest wall substance; evidence of wall, septal, or valvular cardiac disruption; significant tracheal, bronchial, or esophageal injury; mediastinal missile traverse; removal of selective foreign bodies; cardiac herniation (ruptured pericardium), and post-traumatic-contained empyema.[27],[28],[29],[30]

A total of 16 (9.9%) patients had thoracotomy, the commonest indication being empyema thoraces from delayed presentation or infected chest tube thoracostomies. Only three of the thoracostomies were for massive hemothorax. The thoracotomy rate is higher than our previously reported rate but similar to a more recent study by Okugbo et al. from Benin City, Nigeria.[10]

The commonest complication of the management was wound infection occurring in 4.3% of the patients. This is in keeping with the previous finding from our center in which infection complications were the most common in trauma patients generally.[31] The complication rate in this study was similar to the 4.4% reported from Zaria.[5] It has been postulated that several of the body's responses to trauma predispose to infection in addition to the fact that the environment in which the trauma is sustained is often dirty. Additionally, treatment of severe chest injury involving closed-chest tube thoracostomy necessarily leaves a foreign body in situ, increasing the risk of infection. Similar risks are observed with the placement of indwelling devices like central venous lines, endotracheal tubes, and urethral catheters for prolonged periods in trauma patients.[20]

The duration of hospital stay ranged from 1 to 57 days, with a mean of 13.3 days which is similar to Misauno's findings and other studies.[11],[12] Expectedly those with polytrauma or who had thoracotomy stayed longer.

The mortality rate was 5.9%, though slightly higher than the 4.5% previously reported from this center. It is similar to more recent studies.[10],[12],[32] We opine that the presence of more severe injuries, particularly gunshot injuries to the chest might account for the slightly higher mortality. Chest injuries surviving to a treatment center are typically associated with low mortality provided that adequate measures were instituted in a timely manner.


   Conclusion Top


Blunt chest injury remains the commoner mechanism of injury but with an increasing proportion of penetrating injuries affecting predominantly young males. Most severe chest injury patients survive with simple interventions of resuscitation and closed-chest tube thoracostomy for definitive treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Subramanian R. Motor vehicle traffic crashes as a leading cause of death in the United States, 2001. Young 2005;1.  Back to cited text no. 1
    
2.
Sakran JV, Greer SE, Werlin E, McCunn M. Care of the injured worldwide: Trauma still the neglected disease of modern society. Scand J Trauma Resusc Emerg Med 2012;20:64.  Back to cited text no. 2
    
3.
Alberdi F, Garcia I, Atutxa L, Zabarte M. Epidemiology of severe trauma. Med Intensiva 2014;38:580-8.  Back to cited text no. 3
    
4.
LoCicero III J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-9.  Back to cited text no. 4
    
5.
Edaigbini S, Delia I, Aminu M, Shehu H. Profile of chest traumain Zaria, Nigeria: A preliminary report. Niger J Surg 2011;17:1-4.  Back to cited text no. 5
  [Full text]  
6.
Misauno M, Sule A, Nwadiaro H, Ozoilo K, Akwaras A, Ugwu B. Severe chest trauma in Jos, Nigeria: Pattern and outcome of management. Niger J Orthop Trauma 2007;6:64-6.  Back to cited text no. 6
    
7.
Søreide K. Epidemiology of major trauma. Br J Surg 2009;96:697-8.  Back to cited text no. 7
    
8.
Schulpen TM, Doesburg W, Lemmens W, Gerritsen S. Epidemiology and prognostic signs of chest injury patients. Injury 1986;17:305-8.  Back to cited text no. 8
    
9.
Păun S, Beuran M, Negoi I, Runcanu A, Gaspar B. Trauma--epidemiology: Where are we today? Chirurgia (Bucur) 2011;106:439-43.  Back to cited text no. 9
    
10.
Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma center. J Trauma 2004;57:576-81.  Back to cited text no. 10
    
11.
Jegoda RK. Profile of chest injuries in a tertiary care center. Int J Surg 2020;7:714-6.  Back to cited text no. 11
    
12.
Lema MK, Chalya PL, Mabula JB, Mahalu W. Pattern and outcome of chest injuries at Bugando medical centre in Northwestern Tanzania. J Cardiothorac Surg 2011;6:7.  Back to cited text no. 12
    
13.
Anyanwu C, Swarup A. Chest trauma in a developing country. Ann R Coll Surg Engl 1981;63:102-4.  Back to cited text no. 13
    
14.
Albadani MN, Alabsi NA. Management of chest injuries: A prospective study. Yemeni J Med Sci 2011;5:5.  Back to cited text no. 14
    
15.
Ali N, Gali B. Pattern and management of chest injuries in Maiduguri, Nigeria. Ann Afr Med 2004;3:181-4.  Back to cited text no. 15
    
16.
Adebonojo S. Management of chest trauma: A review. West Afr J Med 1993;12:122-32.  Back to cited text no. 16
    
17.
Okugbo S, Okoro E, Irhibogbe P. Chest trauma in a regional trauma centre. J West Afr Coll Surg 2012;2:74-84.  Back to cited text no. 17
    
18.
Iloani A, SundayS E. Illegal guns flooding nigeria, fuelling violence. Daily Trust, 20th. 2016.  Back to cited text no. 18
    
19.
John IA, Mohammed AZ, Pinto AD, Nkanta CA. Gun violence in Nigeria: A focus on ethnoreligious conflict in Kano. J Public Health Policy 2007;28:420-31.  Back to cited text no. 19
    
20.
Udosen A, Etiuma A, Ugare G, Bassey O. Gunshot injuries in Calabar, Nigeria: An indication of increasing societal violence and police brutality. Afr Health Sci 2006;6:170-2.  Back to cited text no. 20
    
21.
Ozoilo KN, Pam IC, Yiltok SJ, Ramyil AV, Nwadiaro HC. Challenges of the management of mass casualty: Lessons learned from the Jos crisis of 2001. World J Emerg Surg 2013;8:44.  Back to cited text no. 21
    
22.
Osaretin I, Akov E. Ethnoreligious conflict and peace building in Nigeria: The case of Jos, Plateau State. Acad J Interdiscip Stud 2013;2:349.  Back to cited text no. 22
    
23.
Ozoilo K, Kidmas A, Nwadiaro H, Iya D, Onche I, Misauno M, et al. Management of the mass casualty from the 2001 Jos crisis. Niger J Clin Pract 2014;17:436-41.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Obilom RE, Thacher TD. Posttraumatic stress disorder following ethnoreligious conflict in Jos, Nigeria. J Interpers Violence 2008;23:1108-19.  Back to cited text no. 24
    
25.
Krause J. A Deadly Cycle: Ethno-Religious Conflict in Jos, Plateau State, Nigeria. Geneva Declaration; 2011.  Back to cited text no. 25
    
26.
Ojo EO, Ozoilo KN, Sule AZ, Ugwu BT, Misauno MA, Ismaila BO, et al. Abdominal injuries in communal crises: The Jos experience. J Emerg Trauma Shock 2016;9:3-9.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Wall MJ, Mattox KL, Chen C-D, Baldwin JC. Acute management of complex cardiac injuries. J Trauma 1997;42:905-12.  Back to cited text no. 27
    
28.
Hunt P, Greaves I, Owens W. Emergency thoracotomy in thoracic trauma-A review. Injury 2006;37:1-19.  Back to cited text no. 28
    
29.
Hoth JJ, Scott MJ, Bullock TK, Stassen NA. Thoracotomy for blunt trauma: Traditional indications may not apply. Am Surg 2003;69:1108-11.  Back to cited text no. 29
    
30.
Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: Analysis of 158 patients of a single center. Injury 2011;42:900-4.  Back to cited text no. 30
    
31.
Ozoilo K, Peter S, Nwadiaro H. The burden of morbidity in polytrauma. Highl Med Res J 2014;14:9-11.  Back to cited text no. 31
    
32.
Chrysou K, Halat G, Hoksch B, Schmid RA, Kocher GJ. Lessons from a large trauma center: Impact of blunt chest trauma in polytrauma patients-Still a relevant problem? Scand J Trauma Resusc Emerg Med 2017;25:1-6.  Back to cited text no. 32
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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