Delayed recognition of serious thoracic injury

Delayed Recognition Thoracic

of Serious

Injury

WILLIAM E. DEMUTH, JR.,M.D.,CarEisle, Pennsylvania, AND M. FALLAH-NEJAD, M.D.,Philudelphia, Pennsylvania

clinical importance. The fatal or life-threatening injury becomes very important both clinically and medicolegally, and it seems worthwhile to discuss delay in diagnosis based upon a ten year experience between January 1, 1955 and December 31, 1964. Seventeen serious intrathoracic injuries were missed immediately after injury during this period. Table I demonstrates the nature of the injury and delay in diagnosis. Ten of the seventeen patients died, and it is believed that all but one died because of the thoracic injury. Lower nephron nephrosis accounted for one death in a patient with myocardial contusion. The diagnosis was made in nine patients only at autopsy. In fourteen a chest injury of some type was suspected on admission, but other more apparent injuries appeared to engage the attention ofthe clinician, and the serious nature of the thoracic injury went unnoticed. There were five patients with cardiac injury and six with tension pneumothoraces. In two of the latter group, both survivors, initial roentgenograms of the chest failed to show a pneumothorax which became manifest seven and thirteen days, respectively, after injury when sudden severe respiratory embarrassment occurred. In our general hospital population we hospitalized approximately three accident victims under thirty years of age for each victim over this age. Despite this fact, fourteen of our seventeen patients in whom the diagnosis was not made on admission were over forty-five years of age, five of them being more than sixty. It is apparent that most of our errors in diagnosis occurred in the group of patients least able to tolerate delays in appropriate treatment. One patient with a ruptured diaphragm was not

From the Department of Surgery, Carlisle Hospital, and the Defiartment of Surnerv. - _. Graduate School of Medicine, lJnive&y of Pekzsylvania, Philadelphia, Pt&sylvania.

ERY FEW SURGEONS who treat large numbers V of patients with traumatic injuries have not

been embarrassed by missing significant injuries. The victim of an injury to the head who is comatose will tax the diagnostic ingenuity of the best of surgeons despite roentgenographic, laboratory, and clinical assessment. Fractures and ruptured abdominal viscera are perhaps the best recognized of these oversights. In most instances the cardiopulmonary system lends itself to rather thorough examination by simple clinical and roentgenographic means in ruling out injury. Dramatic changes in hemodynamics and respiratory function which accompany most serious intrathoracic injuries are usually evident early after injury. There are times, however, when signs and symptoms of fatal or lifethreatening chest injuries are slow in developing and difficult to diagnose. Unfortunately, collapse may be the first indication that convalescence from injury is not progressing smoothly. This is especially so in the presence of injuries to large vessels and myocardial contusion. The unexpected delayed development of a sudden tension pneumothorax, especially in the aged, may be fatal before steps can be taken to correct the pathophysiologic disorder. Delayed fatal or life-threatening situations may arise after chest injury and surgeons should be more aware of the possibility of their occurrence. Reference to overlooked injuries have previously been alluded to in our reports of cardiac [I] and pulmonary [Z] injuries. The overlooked rib fracture, minor pneumothorax, or minimal pleural effusion are generally of little Vol. 111, April

1966

587

588

DeMuth and Fallah-Nejad TABLE DATA ON PATIENTS \r’ITH

Patient

WY?)

Thoracic

Injury

Type of Accident

Associated

Injury

1

58, M

Aortic rupture

Auto

Ruptured

2

21, M

Aortic rupture

Auto-train

3

70, F

Heart contusion*

Auto

Fracture of sternum and 4 ribs; contusion of heart Fracture of femur; bilateral rib fractures

4

83, F

Heart contusion*

Auto (pedestrian)

Fracture

6 6

63, F 49, M

Heart contusion* Heart contusion*

Unknown Auto

Fractures of the ribs Fracture of the pelvis; ruptured ileum

7

49, M

Heart contusion*

Auto

Perforation

:

19, M 47, M

Left diaphragm Left diaphragmt

Stab wound in left thorax Auto

Left lung Fracture of left tibia and 3 ribs

10

19, M

Lung contusion

Auto

Fracture of left scapula; heart contusion

11

70. M

Infected hemipneumothorax

Fall

Fracture of radius, ulna and pelvis

12

59, M

Tension pneumothorax

Auto

Fracture of ribs

13

53, M

Tension pneumothorax

14 16

47, M 69, M

Tension pneumothorax Tension pneumothorax

Fall; patient examined immediately and discharged Fall Gunshot to neck

Fracture of ribs; preexisting lungs Fracture of 2 ribs Esophagus

16

47, M

Tension pneumothorax

Auto

Compound liver

17

63, M

Tension pneumothoraxt

Gunshot wound in suicide attempt; tangential chest wall wound

Gunshot wound in l&t chest wall; pleura not entered

diaphragm

of the rib

of ileum; fracture of the ribs

fracture

bullae in

of ankle,

ruptured

* Previously reported. t Reported in detail in text.

seriously ill but his history

is so interesting

that it is reported in detail. CASE

REPORTS

A forty seven year old white man was admitted to the hospital because of persistent nausea. Four years prior to admission he had been involved in a head-on collision and was unconscious for several hours, Diagnoses of fracture of the left tibia and fibula, fractures of several ribs, and cerebral concussion were made. His pain in the chest subsided within a week or so of injury. According to the patient, a roentgenogram of the chest at the time of injury showed “a small amount of fluid around the left lung.” We were unable to obtain the roentgenograms which were alleged to show the pleural effusion. During convalescence he had experienced severe nausea which was attributed to the narcotics which had been administered; the nausea, however, had never completely subsided after cessation of narcotic administration. The patient had never vomited. Nausea prompted roentgenographic studies of the intestinal tract and large segments of the stomach and left colon were found to lie within the CASE

I.

left thorax. A large defect in the dome of the left diaphragm through which these viscera protruded was demonstrated at thoracotomy. The edges of the diaphragmatic defect effectively held these structures within the thorax. Repair resulted in complete subsidence of symptoms. Comment: This patient was an executive whose disability did not seriously impair his ability to make a living. His nausea made him extremely uncomfortable, however, and considerable persuasion was required to avoid medicolegal action because of this disability. Unusual circumstances may give rise to special hazards. The cardiopulmonary system is notoriously affected by the aging process, and injuries are poorly tolerated because of the lack of reserve function. The following case report is a pertinent example. A sixty three year old man who had CASE II. been moderately emphysematous for several years became despondent and attempted suicide by firing a .303 Savage rifle at his chest. Alarge tangential soft Amevican Journal of Surgery

Thoracic

Injury

I SEVERE

THORACIC

INJURY

Delay

Comment

Sudden collapse during suturing of minor aspiration negative on admission Shock; blood pressure 80/40 mm. Hg

laceration;

pleural

Chest pain; blood pressure of 90/40 mm. Hg, pulse 140 per minute: ECG chanaes present. but iniurv not diaanosed Blood pre&“re 140/75m&. Hg, pulse 90 p&min., chest pain present; ECG not taken Blood pressure 180/100 mm. Hg, pulse 100 per min. No roentgenogram of the chest; blood pressure of 136/80 mm. Hg, pulse of 100 per min. Pulse, 100 per min.. respiration 44 per min.; “o ECG or chest roentgenogram performed Shock; small pneumothorax on admission Constant nausea. x-ray film showed “small pleural effusion on admission” Gradual somnolence to deep coma in 6 hr.; pulse 160 per min.; walked into dispensary; thought to have intracranial hemorrhage Septicemia; temperature between 103’ and 104’~_; roent. genograms of chest not take” Sudden cyanosis and shock; blood pressure 50/? roentgenogram of chest noncontributory except tured ribs on admission Severe dyspnea; extreme subcutaneous emphysema

mm. Hg; for frac-

Sudden cyanosis and dyspnea (emphysema before injury) Collapse, hemoptysis; roentgenogram of chest noncontributory on admission Sudden collapse 10 hr. after admission as anesthetic was being introduced; blood pressure of 40/? mm. Hg; x-ray film on admission showed only 4 fractured ribs Sudden collapse, marked tension pneumothorax, contralateral pulmonary contusion; x-ray film of the chest noncontributory on admission

4 hr.; death from cardiac arrest cotomy was begun 16 days; patient exsanguinated tracheostomy wound; diagnosis 10 days; diagnosis at autopsy 6 hr.;

48 hr.;

April

1966

Died

through at autopsy

Died Died Died

diagnosis

at autopsy

at autopsy

Died Died with nephrosis Died

40 hr. 4 yr.

Alive Alive

6 hr.

Alive

96 hr. postoperative; after admission;

open reduction on day diagnosis at autopsy

Alive

2 days

Alive

2 weeks 11 hr; diagnosis pneumothorax 10 hr.

5 days;

diagnosis

at autopsy

as tension

lower

nephron

Died

7 days

Comment: The enormously damaging effect of high velocity bullets is not appreciated by many surgeons who treat traumatic injuries. The lateral force expended by a bullet in the development of the temporary cavity associated 111,

as thora-

at autopsy

10 hr.; diagnosis at autopsy 3 days postlaparotomy; diagnosis

tissue wound of the left axillary region was sustained, and the examining physician did not believe that ribs were broken or pleura damaged. The patient was first seen forty-eight hours after being wounded and, consequently, only surgical debridement was carried out. Chest roentgenograms were not taken. The patient, a recluse, made a remarkable adjustment to hospital care, became cheerful, ate voraciously, and seemed to have only a minor injury. While sitting up eating a meal on his fifth postinjury day, he became markedly dyspneic, suddenly collapsed, and died within thirty minutes. A pulmonary embolus was suspected, but autopsy demonstrated a marked tension pneumothorax on the side of injury and a severe contralateral lung contusion. It is believed that emphysema compromised pulmonary function to such an extent that the insult of collapse was incompatible with life.

Vol.

diagnosis

Outcome

in Recognition

Alive Died Alive

Died

at autopsy

with such wounds may give rise to severe injury even in the contralateral hemithorax, especially if a tangential (bone and muscle) wound is pres-

ent. Were this better understood by the attending physician, the fatality may have been avoided. We do not know if a pneumothorax was present immediately after injury. COMMENTS

It is obvious that the principal source of missed diagnosis was the failure to employ ordinary diagnostic measures. If chest roentgenograms and electrocardiograms had been taken on all of these patients, it is probable that most of the mortality could have been avoided. Inherent in this premise, however, is proper interpretation of the findings. The widened superior mediastinum should suggest that a ruptured aorta is present. Contrary to expectation, the ruptured thoracic aorta may be easily masked by a variety of associated injuries. The literature contains

590

DeMuth

and Fallah-Nejad

many instances of delayed free rupture of a subadventitial aortic tear days or weeks after injury [3-51. Aortography should be used without hesitation if this diagnosis is entertained. Roentgenographic evidence of a widened superior mediastinum, especially in the patientwho is in shock or whose shock responded to treatment, is a definite indication for aortography. Once free rupture occurs, few patients will survive even if they are in the hospital when it happens. The ruptured diaphragm and continued intrathoracic bleeding are best detected by obtaining frequent roentgenograms of the chest in the first two or three days after injury. Tachycardia and abnormalities in the electrocardiogram (S-T segment changes principally) should lead one to suspect a myocardial injury. Significant hemodynamic changes, murmurs, and rapidly developing cardiac failure should focus attention on the possibility of valve or chordae injuries. In our series pericardial tamponade was not a cause of death, but it is one of the most lethal complications which may occur a week or more after injury. Inasmuch as positive pressure respiratory devices such as those of March, Bennett, and Bird are being used more commonly for thoracic injuries of all types, a word of caution concerning the method of evacuation of air and blood from the ,pleural space is timely. We have always favored the use of tube drainage over needle aspiration. When positive pressure devices are used there is a definitely increased risk of development of tension pneumothorax [s]. Tube drainage will avoid the hazard of this lethal complication. The legal implications become obvious when it is noted that the majority of deaths were di-

rectly attributable to the intrathoracic injury despite the fact that other injuries were almost invariably present. These patients were cared for by six different surgeons each of whom was experienced in the care of severe injuries; the number of missed injuries seemed to be well distributed among this group of surgeons, and it appears that long experience did not protect the surgeon from overlooking thoracic injuries. SUMMARY

An experience with seventeen fatal or lifethreatening thoracic injuries encountered in a single hospital in a ten year period is reported. Associated severe injury was almost always present, and it is assumed that the attention of attending physicians was distracted to some degree. Failure to obtain initial roentgenograms of the chest and electrocardiograms accounted for many mistakes. Repeated careful evaluation will avoid missing most serious injuries. REFERENCES

1. DEMUTH, W. E. and ZINSSER, H. F. Myocardial contusion. Arch. Int. Med., 115: 434, 1965. 2. DEMUTH, W. E. and SMITH, J. M. Pulmonary contusion. Am. J. Surg., 109: 819, 1965. 3. GWATHMEY, 0. and BYRD, C. W. Clinical experience with acute traumatic rupture of the thoracic aorta in a general hosnital. Ann. Sure.. 159: 846, 1964. 4. FLEISC~A~CER,R. J., MAZUR, J.-H., and BAISCH, B. F. Surgical treatment of acute traumatic rupture of the thoracic aorta. J. Thorucic & Curdiovus. Surg., 47: 289, 1964. 5. MCKNIGHT, J. T., MEYER, J. A., and NEVILLE, J. F. Nonpenetrating traumatic rupture of the thoradc aorta. Ann. Surg., 160: 1069, 1964. 6. HALLER, A. A. Discussion of: Factors influencing survival after flail chest injuries. Arch. Surg., 91: 216, 1965.

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