Epidemiology and prognostic signs of chest injury patients

Injury (1986) 17,305308

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Symposium paper Epidemiology Th. M. J. Schuipen, University

Hospital,

and prognostic signs of chest injury patients W. H. Doesburg, Nijmegen,

W. A. J. Lemmens

and S. M. Gerritsen

The Netherlands

Summary Accidental injury is the leading cause of death in persons between the ages of 1 and 50 years in our Western society. In spite of a better knowledge of the pathophysiology involved and greater availability of specific resuscitative measures, the mortality rate of patients with severe injuries of the chest has not improved much. This study was carried out to survey and evaluate our own experience with injuries of the chest and to look for prognostic factors related to these and to the often associated injuries of other parts of the body. The case records of 828 consecutive injured patients treated in our critical care department

during the period 1975-1984 were retrospectively analysed. The overall mortality rate was 15 per cent for those with injuries of the chest. The best prognostic indices were the Glasgow Coma Scale and the Injury Severity Score.

INTRODUCTION LARGE series of patients with injuries of the chest are described in the literature but the results of treatment

are difficult to compare because a description of the severity of general injury is not given. In the past decade, methods of scaling injuries have been developed. This study analyses a large series of patients with injuries of the chest by means of the Injury Severity Score, which enables the accompanying injuries of other parts of the body to be taken into account.

movement of the chest were ventilated mechanically until the paradoxical movement had disappeared and the blood gas analyses were satisfactory. For each patient a multiple organ failure (MOF) score was calculated as described by Goris et al. (1985). RESULTS Of 828 injured patients, 396 had injuries of the chest, 46 of them with paradoxical movements (Table I). The peak age incidence for injuries affecting both the chest and other parts of the body was between 16 and 25 years. The mean ISS was 33 for injuries without paradoxical movements, 38 where paradoxical movement was present and 28 when the chest had not been injured (Table I). The mean duration of artificial ventilation was 21 days for unstable chests, 9 days for stable chests and 5 days for other injuries. Tracheostomy was carried out in 185 patients, nearly always because of severe cerebral injury (Table I). The mode of injury is shown in Table II, and Table 111 shows the distribution of the different degrees of injury of the chest according to the HTI. Tab/e 1. Patients (N=828) with and without injuries of the chest admitted to an intensive care unit, 1975-1984 Chest injuries

MATERIAL AND METHODS The case records of 828 injured patients treated in our critical care department between 1 January 1975 and 31 December 1984 were reviewed. All injured patients who were admitted to our department were included in this study; 396 had suffered injuries of the chest, 46 of them with paradoxical movement. The Injury Severity Score (ISS) was determined for each patient, using the Hospital Trauma Index (HTI) (Baker et al., 1974; American College of Surgeons, 1980). The score 6 that is provided in the HTI was not utilized in calculating the IS& so the maximum score was 75. Patients who died within 24 hours because of a severe head injury were accorded an HTI score of 5 for brain injury. In this hospital for 8 years we have used a scale that is intended to try to reduce the risk of the adult respiratory distress syndrome. Patients with 10 points or more on the scale were intubated and ventilated for 24 hours in order to prevent the adult respiratory distress syndrome (Goris et al., 1982). Patients with paradoxical

With paradoxical movement Number Women Men Ag;J;;ars) Range ISS (mean) Mechanical ventilation Mean Median Not ventilated Stay in KU (days) Mean Median Tracheostomy Thoracotomy Died Mortality rate (%)

Without paradoxical movement

No chest

injury

46 9 36

350

432

99 251

121 311

52 17-82 38 (days) 21 19 -

34 l-82 33

30 2-90 24

9 6 60

5 2 80

25 23 17 7 9 20

12 7 81 36 51 15

7 3 86 77 18

Injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 5

13 (57%)

78 (42%)

54 (26%)

6 (26%)

51 (27%)

70 (34%)

3 (13%)

13 (7%) 6 (3%)

22(11%) 4(2%)

The mortality rate was 15 per cent with stable chests, 20 per cent with paradoxical movement and 18 per cent for other injuries. Causes of death are shown in Table IV. Patients dying of cerebral dysfunction mostly died in the first days of stay. Patients dying after 7 days mostly died of MOF (Table V). Several prognostic indices have been studied in the literature. As could be expected, we found a good correlation between ISS and mortality rate (Table Vo. Although the mortality rates were higher in the victims of chest injury over the age of 60 or with a low Horrowitz score (Pao,lfio, determined on the first hours of admission, without positive end-expiratory pressure) or with injuries of the chest and abdomen

57 (27%) 207(100%) 18

Table VI. Mortality rate of patients with injured chests related to the Injury Severity Score (ISS)

Tab/e II. Mode of injury in 440 patients with and without chest injury admitted to an intensivecare unit, 1980-1984 Chest injuries With paradoxical movement Car Pedal cycle Moped I Motor Pedestrian Stab and bullet injuries Others Total Data unknown

Without paradoxical movement

1(4%) 23 (100%) -

40 (21%) 188 (100%) 4

No chest injury

Tab/e 111.Hospital Trauma Index (HTI) in 396 patients with injuries of the chest

Total no.

Respiratory Cardiovascular CNS Abdominal Limbs Skin and subcutis

1

129 104 214 118 274

43 92 47 20 18 109

2

3

4

45 185 70 43 78 37 58 57 49 55 50 45 67 103 68 11 1 l-

5

of patients

53 17 81 12 22

396 396 396 396 396 396

Mortality rate (%l

1 5 32 72 77 74 71 59 5 396

O-4 5-8 9-15 16-24 25-33 34-38 3949 50-66 75 Total

HTI 0

No of patients

ISS

0 0 0 7 9 14 17 37 80 15

Tab/e IV. Cause of death in relation to the mean Injury Severity Score (ISS) and mean length of stay in the intensive care unit Chest injuries With paradoxical movement

Cause of death

N

ISS

Cerebral Cardiac* Haemorrhage” Sepsis* Respiratory* Cardiorespiratory* Other

1 4 1 1 1 1 --

66 37 57 50 34 43

Without paradoxical movement

Stay (days)

N

ISS

1 26 2 13 1 9 -

30 4 6 6 3 1 1

49 32 46 40 41 34 34

No chest injury

Stay (days) 4 I: 29 42 13 1

N

ISS

Stay (days)

6531 2 5 4 1 -

5 32 31 9 -

3 9 10 10 11 -

* Mostly due to MOF.

Tab/e V. Multiple organ failure (MOF) score of survivors and patients who died within and after 7 days of injury (1980-1984) Chest injuries With paradoxical movement

Survivors Died

~7

days

Died >7 days Insufficient data available

Without paradoxical movement

No chest injury

MOF score

(N)

MOF score

(N)

MOF score

(N)

2.1

(180) (28)

(19)

1.3

(151)

0.8

0

(2)

1.8

(17)

1.3

5.5

(2) (-1

5.3

(11) (13)

5.0

(2) (15)

Schulpen et al.: Chest injuries

307

Table VII. Mortality rates of patients with injured chests according to HTI for injuries of the abdomen and limbs and to Horrowitz score and age No. of patients

No. of deaths

Mortality fate (%I

289 107

41 21

14 20

0.11

203 193

35 25

17 13

0.25

Abdominal HTI a2 HTI 23 Extremities HTI ~2 HTI 23 Horrowitz” 340 <40 Age (years) ~60 a60 *The Horrowitz 1980-1984 only.

Chi squared test, P value

67 93

9 21

13 22

o-21

323 74

45 15

14 20

0.15

score

was

determined

during

the

period

Table VIII. Mortality rate of patients with injured chests in and Glasgow Coma Scale relation to shock (X2,=40.6, RO.001). In 28 patients data were insufficient

Table IX. Mortality rates of patients with paradoxical movement and other injuries of the chest treated in an intensive care unit Year of publication

Author

No. of patients

Mortality rate l%l

injuries of the chest Faso1 Racenberg Dougall Pinilla Richardson

1975 1977 1977 1982 1982

191 353 144 427

28 25 18 8 7

Paradoxical Paris Shackford Dougall Carpintero Shackford Bertelson Miller Pinilla

1975 1976 1977 1980 1981 1981 1983 1982

29 42 44 30 36 14 82 63

48 14 20 13 8 21 10 10

101

movement

Like others (Conn et al., 1963; Sankaran and Wilson, 1970; Wilson et al., 1977b; Pinilla, 1982; Richardson et Glasgow Coma Scale al., 1982; Miller et al., 1983) we found that in patients with injured chests, mortality increases with higher ISS, 3-5 6-7 8-15 lower Glasgow Coma Scale values and when the patient was in shock. Mortality Mortality Mortality In contrast to others (Racenberg et al., 1977; Wilson rate No. rate No. rate No. Shock et al., 1977b) we found no correlation between mortality and a low Horrowitz score, a severe abdominal Yes 50% 9118 0% o/3 17% 7142 injury, a higher HTI score for extremities or age above No 28% 24186 16% 4125 6% 12/I 95 60 years. Recently, it became clear that the respiratory insufficiency occurring in flail chest patients is not a conse(HTI >3), these differences were not statistically signi- quence of ‘Pendelluft’ (unless there is a partial tracheal obstruction), but a consequence of the underlying pulficant in our material. Also, the combinations of injury of the chest with monary contusion and other factors like haemoinjury of limbs showed no statistically significant differ- pneumothorax, pain and atelectasis (Faso1 et al., 1975; ence in our material (Table VU). The mortality rate of Shackford et al., 1976, 1981; Wilson et al., 1977a; Carpintero et al., 1980; Richardson et al., 1982). In the patients with injured chests was strongly correlated with the combination of a low Glasgow Coma Scale and past decade there has been a tendency to ventilate shock (arterial blood pressure below 80mmHg) (Table patients only in cases of respiratory failure, severe neurological dysfunction, shock or after aspiration of VIII). liquid or solid (Faso1 et al., 1975; Shackford et al., DISCUSSION 1976; Safar et al., 1978; Carpintero et al., 1980; Table IX shows mortality rates for patients with chest Richardson et al., 1982). Wilson et al. (1977a) showed a injuries and paradoxical movements as described in the notable drop in mortality rate for patients with paraliterature. The mortality rates range from 7 to 28 per doxical respiration, after early intubation and ventilacent and 8 to 48 per cent respectively. These mortality tion. Indications for this treatment were shock, three or rates are not comparable because objective scoring more associated injuries, severe head injury, previous methods reflecting the severity of injury were presented pulmonary disease, eight or more rib fractures and high in only one study. Miller et al. (1983) reported an ISS in age (>6.5 years). In this series, the mortality rate of 46 only a part of their series of patients with paradoxical patients with paradoxical movements (mean ISS 38) respiration. In this series of 396 patients the mean ISS was 20 per cent. The mean ISS of the 9 patients who was 34. The mortality rate was 15 per cent, and the died was 44. mean ISS of the patients who died was 45. In contrast In our series head injury was the main cause of death to others who showed a peak incidence for chest in- in 70 per cent; 52 per cent of deaths with injuries of the juries in patients in the third decade (Ashbaugh et al., chest were due to head injury. MOF was the second 1967; Pinilla, 1982), the peak incidence in this series most common cause of death. We agreed with Safar was between 16 and 25 years. Our series contains only a (1978) that future development in critical care should few penetrating injuries, in contrast to the epidemiobe sought in improved methods of management of inlogy of chest injuries in the USA (Conn et al., 1963; juries of the brain. Research in the pathophysiology Wilson et al., 1977b). and treatment of MOF should also be encouraged.

Injury:

308 REFERENCES

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Requests for reprinfs should be addressed Netherlands.

tot Th.

M.

J. Schulpen,

the British Journal

of Accident

Surgery

(1986) Vol. 17/No. 5

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17.

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Department

of Critical

Care,

University

Hospital,

Nijmegen,

The