What is the difference between a thoracic and an abdominal injury

Because the diaphragm can be as high as the nipple line during exhalation, penetrating trauma to the chest at or below nipple level can also cause intra-abdominal injuries. Most morbidity and mortality due to chest trauma occurs because injuries interfere with respiration, circulation, or both.

Injuries that directly damage the lung or airways include pulmonary contusion and tracheobronchial disruption. Injuries that alter the mechanics of breathing include hemothorax Hemothorax Hemothorax is accumulation of blood in the pleural space.

Symptoms include chest pain from the causative injury and sometimes dyspnea The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to This air itself rarely has significant physiologic consequence; the underlying injury is the problem. Tension pneumothorax Pneumothorax Tension Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart.

Bleeding, as occurs in hemothorax, can be massive, causing shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes Decreased venous return impairs cardiac filling, causing hypotension. Decreased venous return can occur due to increased intrathoracic pressure in tension pneumothorax or to increased intrapericardial pressure in cardiac tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling.

Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid Because chest wall injuries typically make breathing very painful, patients often limit inspiration splinting.

A common complication of splinting is atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually Patients treated with tube thoracostomy Thoracotomy Thoracotomy is surgical opening of the chest.

It is done to evaluate and treat pulmonary problems when noninvasive procedures are nondiagnostic or unlikely to be definitive. The principal indications Symptoms include pain, which usually worsens with breathing if the chest wall is injured, and sometimes shortness of breath. Common findings include chest tenderness, ecchymoses, and respiratory distress; hypotension or shock may be present.

Neck vein distention can occur in tension pneumothorax Pneumothorax Tension Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. Decreased breath sounds can result from pneumothorax or hemothorax Hemothorax Hemothorax is accumulation of blood in the pleural space.

Subcutaneous emphysema causes a crackling or crunch when palpated. Most often, pneumothorax is the cause; when extensive, injury to the tracheobronchial tree or upper airway should be considered. Air in the mediastinum may produce a characteristic crunching sound synchronous with the heartbeat Hamman sign or Hamman crunch. Hamman sign suggests pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices.

Open pneumothorax Pneumothorax Open Open pneumothorax is a pneumothorax involving an unsealed opening in the chest wall; when the opening is sufficiently large, respiratory mechanics are impaired. Pericardial tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Diagnosis and treatment begin during the primary survey see Approach to the Trauma Patient Approach to the Trauma Patient Injury is the number one cause of death for people aged 1 to Depth and symmetry of chest wall excursion are assessed, the lungs are auscultated, and the entire chest wall and neck are inspected and palpated.

Patients in respiratory distress should be monitored with serial assessments of clinical status and of oxygenation plus ventilation eg, with pulse oximetry, arterial blood gas tests, capnometry if intubated. Penetrating chest wounds should not be probed. However, their location helps predict risk of injury. High-risk wounds are those medial to the nipples or scapulae and those that traverse the chest from side to side ie, entering one hemithorax and exiting the other. Such wounds may injure the hilar or great vessels, heart, tracheobronchial tree, or rarely the esophagus.

Patients with symptoms of partial or complete airway obstruction following blunt trauma should be immediately intubated to control the airway. In patients with difficulty breathing, severe injuries to consider during the primary survey include the following:. Many chest injuries cause death during the first minutes or hours after trauma; they can frequently be treated at the bedside In patients with thoracic trauma and impaired circulation signs of shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death.

Other chest injuries eg, blunt cardiac injury, aortic disruption may cause shock but are not treated during the primary survey. However, hemorrhage should be excluded in all patients who have shock after major trauma, regardless of whether a chest injury that could cause shock is identified.

Treatment of injuries affecting the airway, breathing, or circulation begins during the primary survey. Traumatic rupture of the diaphragm. Int J Clin Pract. Ruptures du diaphragme. A propos de 13 ruptures traumatiques anciennes. Ann Chir. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma. Diaphragmatic hernias due to blunt thoracoabdominal trauma. Ital J Surg Sci. Traumatic injuries of the diaphragm. Experience in 33 cases. Thorac Cardiovasc Surg. The characteristics and surgical approach in post-traumatic diaphragmatic hernia: a single center experience.

Bull Emerg Trauma. Management of delayed presentation of a right-side traumatic diaphragmatic rupture. World J Surg. Management of traumatic diaphragmatic rupture.

Surg Today. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg. Traumatic diaphragmatic hernias. Analysis of six cases. J Natl Med Assoc. Diaphragmatic rupture due to blunt trauma: morbidity and mortality in 42 cases. South Med J. Management of patients with traumatic rupture of the diaphragm. Korean J Thorac Cardiovasc Surg. Diaphragmatic Injuries in childhood.

Traumatic diaphragmatic hernia with delayed presentation. Laparoscopic management of blunt diaphragmatic injury. Aust N Z J Surg. Traumatic disruption of the diaphragm: emergency diagnosis and treatment. Eur Surg. Traumatic diaphragmatic hernia. Report of 50 cases. Acta Chir Scand. Traumatic rupture of the diaphragm: experience with 65 patients. Diagnosis and treatment of traumatic diaphragmatic hernia with delayed presentation.

Minerva Chir. Surgical management of traumatic rupture of the diaphragm. Delayed presentation of posttraumatic diaphragmatic hernia. Traumatic diaphragmatic rupture in children. J Pediatr Surg. Olin C.

Report of eleven cases. Trauma mechanism and diagnosis of blunt diaphragmatic rupture. Arch Surg. Plate H, Demischew M. Neglected traumatic diaphragmatic rupture in a thoracic surgery patient sample. Zentralbl Chir. Diagnosis and therapy of diaphragmatic rupture after blunt thoracic and abdominal trauma. Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture. Sharma OP. Traumatic diaphragmatic rupture: not an uncommon entity - personal experience with collective review of the 's.

Traumatic diaphragmatic rupture: associated injuries and outcome. Ann R Coll Surg Engl. Sixty-three cases of traumatic injury of the diaphragm. Management of diaphragmatic rupture from blunt trauma.

Singapore Med J. Traumatic diaphragmatic rupture: look to see. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. Diaphragmatic rupture in abdominal trauma.

Ulus Travma Derg. Traumatic diaphragmatic rupture: results of the chest surgery clinic. Financial source: none. Part of Master degree thesis, Postgraduate Program in Medicine. Tutor: Antonio Jose Maria Cataneo. Publication Dates Publication in this collection Jan This is an open-access article distributed under the terms of the Creative Commons Attribution License. Figures 7 Tables 1.

South Africa 32 does not refer Alar et al. Turkey 29 does not refer Aliev et al. Grek 32 does not refer Al-Salem 12 Saudi Arabia 7 to Antoini, et al. Arbogast R, Gay B. Ruptures traumatiques du diaphragme. Germany 34 to Athanassiadi et al. Greece 41 to Basso et al. Chile 3 does not refer Beauchamp et al. Canada 24 to Beigi et al. Spain 7 to Chen; Wilson 20 USA 62 to Clarke et al. France 13 does not refer Feliciano et al.

USA 16 to Forni et al. Italy 50 19 years Freixinet et al. Spain 33 to Ganie et al. India 21 does not refer Gao et al. China does not refer Garbuio et al. Saudi Arabia 10 to Guner et al. Turkey 8 to Gwenly2 7 7. Egypt 44 to Haciibrahimoglu et al. Turkey 18 to Hani 32 Jordan 4 to Hegarty et al. England 42 to Hwanget al. Turkey 15 to Kishore, et al. France 21 to Lin et al. China 24 does not refer Lindseyet al. Australia 3 does not refer Losanoff et al.

USA 45 to Matsevych 1 1. South Africa 12 to Matthews et al. Finland 50 to Matz et al. Israel 3 to Mihos et al. Italy 5 does not refer Nadal et al. Brazil 5 to Noonet et al. USA 22 to Okan et al. Turkey 10 to Okur et al. Sweden 11 to Pantelis et al. Germany 21 to Payne; Yellin 55 Germany 10 34 years Ruf et al.

Germany 99 to Sanli et al. Turkey 13 does not refer Sharma 59 Turkey 8 to Sukul et al. USA 25 to Tan et al. Italy 33 to Turhan et al. Netherlands 28 does not refer Vatansev et al. Google Google Scholar. Adamthwaite 9 9. Alar et al. Aliev et al. Al-Salem 12 Antoini, et al.

Arbogast; Gay 14 Athanassiadi et al. Basso et al. Beauchamp et al. Beigi et al. Brown; Richardson 18 There were patients included.

Patients were divided into two groups; group I included patients presenting with thoracic trauma between January and December no dedicated thoracic surgeons were available. Forty-eight patients with thoracic trauma were excluded due to incomplete data. Simple means were used for frequency and percentages for the categorical variables, while standard deviations SDs and the Mann-Whitney U test were used for the comparison of continuous variables.

For multivariable analysis, a Cox regression model was used with a forward stepwise selection of covariates. Between January and December , patients were admitted to our institution due to trauma.

Group I between Jan. Eight percent had signs of aspiration in group I vs. In addition, no significant difference was noticed between the two groups in terms of sex, type of transport, type of accident, blood transfusion or accompanying injuries of other organs. The ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an AIS and is allocated to one of six body regions head, face, chest, abdomen, extremities including the pelvis.

Only the highest AIS in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS. The ISS has values ranging from 0 to The ISS is virtually determined; moreover, it is the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity.

Its weaknesses are that any error in AIS scoring increases the ISS error, many different injury patterns can yield the same ISS, and injuries to different body regions are not weighted. Additionally, as a full description of patient injuries is not known prior to full investigation and operation, the ISS along with other anatomical scoring systems is not useful as a triage tool.

The ISS was summarised and compared between both groups Table 3. The mean ISS was 32 28 in group I vs. The AIS thoracic is an anatomical-based coding system created by the Association for the Advancement of Automotive Medicine to classify and describe the severity of a specific individual injuries.

Car crashes were the most frequent cause among RTAs Falls made up for most of the remaining injuries Injuries caused by bicycles were represented by 7. Associated extrathoracic injuries were most frequent in the head and neck region, the lower extremities and then upper extremities, followed by abdominal injuries and then pelvic injuries. An overview is summarised and compared in both groups Table 1. The most common thoracic injuries were lung contusions followed by haemothorax, rib fractures and then pneumothorax.

The prevalence of common thoracic injuries was analysed and compared in both groups Table 5. The presence of pneumatoceles and other signs of lung lacerations were frequently seen in both moderate and severe lung contusions but did not show significant differences in complication or mortality rates.

The degree of lung contusions was classified according to the findings on CT scans of the lung. The lung contusion volume was calculated according to the relation of the affected lung volume to the non-affected lung volume Fig. The following classification was performed:. There were such patients in group I two patients died, 1. Distribution of pulmonary contusion on X-ray and the corresponding CT-scan.

Complications were documented, analysed and compared in both groups. Organ replacement procedures, e. Other complications, such as reoperation, pleural empyema, cardiovascular events, lung emboli and neurological complications, were higher in group I but did not show significant differences Table 7. Thoracic trauma is one of the leading causes of death in Germany and many other countries worldwide. It is responsible for one-third of all traumatic deaths in the USA.

Blunt thoracic trauma is much more common than penetrating trauma and is increasing worldwide 1, We agree with Veysi et al. In contrast to the findings of Chrysou et al. We explain this finding by the fact that patients with an AIS thoracic score of 4 and especially 5, even without other associated injuries such as head and abdominal injuries, suffered serious complications, especially MOF.

Our results showed the efficacy of using new ventilator strategies with early weaning as well as the generous use of NIV equipment on morbidity and mortality. The causes of death were ARDS, sepsis, aspiration and multiple organ failure.

The overall mortality in group II was significantly lower than that in group I and previously reported studies [ 12 , 14 ]. Over the last decade, there has been a huge change in the strategies of ventilation and the application of NIV or other devices in the field of trauma management.

Furthermore, there were more sophisticated thoracic surgical procedures performed in group II, such as early fixation of rib fractures and the use of minimally invasive procedures such as VATS or mini-thoracotomies instead of standard thoracotomies. Altogether, these findings represent a new synergetic system that may enhance the level of trauma care and could result in better survival for trauma patients. Interestingly, approximately one third of all deaths in our study were attributed to chest trauma itself, showing the importance of immediate thoracic surgical treatment if possible to reduce unnecessary emergency thoracotomies in polytrauma patients.

However, it must also be considered that a significant proportion of deaths attributed to severe chest trauma occur in the prehospital setting [ 15 ]. Although the majority of our patients with blunt chest injury could be treated without surgery In the case of flail chest, early stabilisation is an effective way to avoid long-term intubation [ 17 ]. The degree of lung contusion plays an important role in developing respiratory complications, such as pneumonia and acute respiratory distress syndrome ARDS.

Our results support the hypothesis by Clark et al. In their series, the mortality rate was more than doubled when a combined pulmonary contusion and flail chest were present [ 18 ]. Accordingly, we may assume that a new classification for lung contusion using the affected zone is needed Fig.

We identified a high incidence of left-sided ruptured diaphragms, similar to that in other publications [ 17 , 19 , 20 ]. In contrast to the findings of Rodriguez and colleagues, there were fewer patients who had right-sided diaphragmatic rupture in our study.

Small diaphragmatic rupture is usually difficult to diagnose, and many cases remain occult, especially on the right side [ 21 ]. Emergency thoracotomy ET plays an important role in penetrating trauma but continues to be controversial in blunt trauma. ET might be effective in the treatment of a ruptured cardiac chamber or severe pulmonary parenchymal laceration [ 22 ].

Our general philosophy in case of doubt is to perform ET as it is better to err on the side of resuscitation rather than declaring the patient dead on arrival.

Emergency thoracotomy was frequently performed in group I compared with group II, and these ratios are similar to previously published results [ 3 , 11 , 24 ]. Our results showed a significant decrease in the number of ETs in group II in the presence of a dedicated thoracic surgeon.

This demonstrates the importance of specialised thoracic surgeons at high-frequency trauma centres. VATS as a minimally invasive surgery is an effective method to explore intrathoracic injuries in stable patients. Many reports have identified the efficacy of VATS in cases of thoracic trauma. We agree with Freeman et al. Atelectasis and pneumonia are two of the most common causes of death in ICU patients with multiple injuries, and every effort has to be made to manage these conditions.

The development of nosocomial pneumonia, especially in patients with known COPD or emphysema, has an adverse prognostic effect on the outcome. We postulate that early and complete drainage of haemothorax or pneumothorax, repeated bronchoscopy, early mobilisation, aggressive analgesia, vigorous physical and respiratory therapy, and early use of antibiotic therapy in case of infection are the most important factors to improve the outcome of blunt thoracic trauma.

Mortality rates in polytrauma patients with blunt chest trauma correlate with the severity of chest injury. High ISS greater than 30 , high AIS thoracic score greater than 4 , advanced age and severe lung contusion were independent predictive factors for mortality in our study.

Surgeons with thoracic surgery experience play an important role in the trauma team. Management of blunt chest trauma with corrective chest tube insertion, optimal pain control and chest physiotherapy resulted in good outcomes in the majority of patients. Although the data of all trauma patients were prospectively collected through the German trauma register, this study was dependent on a retrospective analysis.

To validate the results shown herein, multicentric prospective studies are needed. The global burden of injuries. Am J Public Health.