Penetrating Chest Trauma in Nigeria

Chest Trauma Management in Low- and Middle-Income Countries

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

Outcomes of stab wounds presenting to Kamuzu Central Hospital in Malawi

Introduction

Injuries are a leading cause of morbidity and mortality worldwide, necessitating that we understand the local burden of injury to improve injury-related trauma care and patient outcomes. The characteristics, outcomes, and risk factors for mortality following stab wounds in Malawi are poorly delineated.

Methods

This is a retrospective, descriptive analysis of patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, with stab wounds from February 2008 to May 2018. Univariate and bivariate analyses were performed to compare patient and injury characteristics based on mortality. We performed Poisson multivariate regression to predict the factors that increase the relative risk of mortality.

Results

During the study, 32,297 patients presented with assault. Of those patients, 2,352 (7.3%) presented with stab wounds resulting in a 3.2% (n=74) overall mortality. The majority of wounds were to the head or cervical spine (n=1,043, 44.6%), while injuries to the chest (n=319, 13.7%) were less frequent. We found an increased relative risk of mortality in patients who presented with an injury to the chest (RR 3.95, 95% CI 1.79-8.72, p=0.001) and who were brought in by the police (RR 33.24, 95% CI 11.23-98.35, p<0.001).

Conclusion

In this study, stab wounds accounted for 7.3% of all assault cases, with a 3.2% mortality. Though the commonest site of stab was the head, wounds to the chest conferred the highest relative risk of mortality. A multifaceted approach to reducing mortality is needed. Incorporating training of first responders in basic life support, including the police, may reduce stab-related mortality.

Task-shifting of orthopaedic surgery to non-physician clinicians in Malawi: effective and safe?

There is a shortage of orthopaedic surgeons in Malawi. Orthopaedic clinical officers (OCOs) treat trauma patients and occasionally perform major orthopaedic surgery. No studies have assessed the efficacy and safety of their work. The aim of this study was to evaluate their contribution to major orthopaedic surgery at Zomba Central Hospital. Data about orthopaedic procedures during 2006-2010 were collected from theatre books. We selected major amputations and open reductions and plating for outcome analysis and collected details from files. We compared patients operated by OCOs alone ('OCOs alone' group) and by surgeons or OCOs assisted by surgeons ('Surgeon present' group). OCOs performed 463/1010 major (45.8%) and 1600/1765 minor operations (90.7%) alone. There was no difference in perioperative outcome between both groups. OCOs carry out a large proportion of orthopaedic procedures with good clinical results. Shifting of clinical tasks including major orthopaedic surgery can be safe. Further prospective studies are recommended.

Unusual bilateral pneumothoraces due to zone I neck stab wound

Pneumothorax is a known complication of spontaneous or traumatic chest events. Trauma is the most common cause of pneumothorax all over the world. The majority of penetrating pneumothoraces are due to stab wound in Iran. The unilateral pneumothorax commonly is due to chest stab wound but it can be caused by neck stab wound, too. Ipsilateral pneumothorax is an uncommon complication of neck stab wound in zone I. We reported a rare case of bilateral pneumothoraces due to usual unilateral neck stab wound.

Multiple thoracoabdominal impalement injuries

A 20-year-old male was impaled through the chest, abdomen, and right upper thigh by three 1.5 cm (0.59 in) diameter rods, each 2 m (6.56 ft) in length. The first rod entered below his right nipple, the second through the right hypochondrium, and the third through the right upper thigh. He was transported to the hospital with the rods in situ. This paper provides insight as to how these unusual injuries were managed in a limited-resource environment. Even in a developing country, the challenges posed by multiple impalement injuries can be managed successfully by rapid prehospital transfer, along with an adequate and coordinated hospital team effort.

An unusual case of left chest stab wound

A 72-year-old man was admitted with one blade of a huge pair of shears in his left thorax. His hemodynamics deteriorated due to life-threatening vascular lesions. An urgent thoracotomy revealed several injuries to the intercostal vessels and left apical inferior lung lobe. The blade tip was stuck in the posterior chest wall, 2 cm adjacent to the descending aorta. The blade was removed, the lung was sutured, and the patient made a good recovery.

Etiopathology and management challenges of blunt chest trauma in Nigeria

Blunt chest trauma had not been roundly studied in Nigeria. This study was conducted to determine the etiopathological and management challenges of chest trauma in a developing country. In a prospective multicenter hospital-based study of 10-years duration in the city of Lagos, the data of 896 patients were recorded. The male-to-female ratio was 8 : 1, and the mean age was 27.1 years. The majority of patients (76.9%) were aged 20-39 years. Road traffic accidents caused 98.1% of the injuries. Lung parenchymal injuries occurred in 66% of patients, and cardiac trauma in 0.1%. Isolated chest trauma was found in 85% of patients, and 134 had associated injuries. The incidence of blunt chest trauma could be reduced if the number of road traffic accidents in Nigeria is reduced.

Penetrating chest trauma secondary to falling on metallic (iron) bar

Case of a 27-year-old man who sustained penetrating chest injury caused by a metallic (iron) bar projecting from a pillar of a construction after he fell down from a height.

[Aortic thrombi associated with thoracic gunshot wound]

We report the case of a stroke due to a ballistic thoracic traumatism. The vascular injury, provoked by the passage of the bullet, associated to a procoagulating state led to the formation of a thrombus in the ascending aorta. The migration of this thrombus caused a stroke, finally reversible upon medical treatment only.

Management of a massive thoracoabdominal impalement: a case report

A 26 year old male was impaled through his chest and upper abdomen with an iron angle, one and half meter long and five centimeters thick. The iron angle entered the chest, through the epigastrium and exited posteriorly just inferior to the angle of left scapula. The patient was transported to hospital with the iron angle in situ. Positioning the patient for intubation proved a major challenge. An unconventional position for intubation allowed a successful airway management. Paucity of time prevented us from gauging the nature and extent of injury. The challenges posed by massive impalement could be successfully managed due to rapid pre-hospital transfer and co-ordinated team effort.

Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience

Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this retrospective study, we present our 10-year experience in the management and clinical outcome of 4205 cases with chest trauma associated with blunt and penetrating injuries in a level I trauma hospital in Turkey. In 66% of the cases, blunt injury mostly related to traffic accidents was the cause of chest trauma. Additional organ injuries were found in 35% (n=1471). Conservative treatment was administered for most patients. Tube thoracostomy was administered in 40% of all cases, whereas thoracotomy was performed in 6% (n=252), of which 209 were early interventions (P=0.001). The morbidity rate in all victims was 25.2%. The mortality rate was 9.3% for all patients and was 6.8% in blunt, 1.4% in penetrating, and 17.7% in associated organ injuries. Mortality and injury severity score (ISS) increased in patients having early surgery (P=0.001). Although most patients could be managed with conservative approaches, early thoracotomy was required in some cases. We believe that urgent hospital admission, early diagnosis, and multidisciplinary approach are very important to improve outcome.

Emergency department at the cutting edge

OBJECTIVE

This paper reviews the experience of penetrating chest trauma over a 3-year period in one UK emergency department.

METHODS

A retrospective review was performed of patients assessed in the emergency department resuscitation room between 1 January 2002 and 31 December 2005. Patients with penetrating chest trauma, either isolated or in combination with other injuries, were included. A Medline search was performed using the terms 'chest', 'trauma' and 'penetrating'.

RESULTS

A total of 120 patients presented with penetrating chest trauma. Ninety-two percent were male. Ninety-six percent (115) of the patients survived to hospital discharge. Seventy-eight percent of the patients presented at night (20.00 and 8.00 h). A single wound accounted for 52% (63) of patients, multiple wounds 43% (52) with 2% (two) gun-shot wounds and 3% (three) impalings. The mean prehospital time of patients in cardiac arrest was 42 min with a mean on-scene time of 24 min. The mean prehospital time for patients undergoing formal emergency surgery was 39 min with a mean on-scene time of 16 min. Twenty-three patients required one or more tube thoracostomies to be performed in the emergency department and six underwent emergency department thoracotomy. Sixteen patients required immediate formal emergency surgery for haemorrhage control.

CONCLUSION

Penetrating chest trauma contributes significantly to our trauma workload with a high proportion of patients sustaining life-threatening injuries requiring immediate intervention. Significant prehospital delays occur. Overall mortality of 4.2% is comparable with that of a major American case series. Further education and protocol development is required to ensure that prehospital and emergency department management of these patients reflects the latest evidence-based guidelines.