الفهرس 
Initial TreatmentOnly 14 pages are availabe for public view
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Abstract
Trauma is the 3rd cause of death exceeded by cardiovascular disease and cancer. It ranks 1st in the age group between 15-35. 25% of trauma mortalities are 2ry to chest trauma. In another 25% of trauma mortalities chest trauma aids significantly to the deaths. Injury to the thorax alone carries a mortality of 4-12%.
Blunt chest injuries tend to have a much higher mortality than penetrating injuries because of the propensity for multiple system damage, particularly head trauma. They are responsible for 50,000 deaths and 1.5 million disabling injuries every year. Motor vehicle accidents plays a major role in the causation of these trauma, however, the improvements in motor vehicle seat belts and air bags have helped to decrease this morbidity and mortality.
The danger and importance of thoracic trauma lies in that the result of all types of chest trauma in their acute phase is disrupted tissue perfusion with attendant hypoxia and metabolic acidosis. Therefore the initial care must involve an accurate diagnosis and appraisal of those anatomic or pathologic states that threaten the patient’s life.
• Rib Fracture & Flail Chest
Despite many advances in overall trauma care and improvements in ventilatory support the mortality rate has not changed appreciably over the past decades. The majority of deaths in patients with flail chest is due to associated injuries. Mortality rate varies in different studies from 11 to 40%.
In conclusion, I would like to stress that:
1. Injury severity score (ISS) was found to a strong predicator on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate.
2. Mechanical support was not considered a necessity for the treatment of flail chest, while the maintenance of pulmonary and tracheal hygiene and pain control with local or systemic analgesia along with aggressive treatment of associated injuries were essential.
• Tracheobronchial Injury
Tracheobronchial injuries are uncommon, but usually occur after high-energy impact and are associated with trauma to other vital organs. According to the published tracheobronchial injuries since 1873 till nowadays, 59% of these injuries are due to motor vehicle accidents, 76% occur within 2 cm of the main carina, and 43% are located within 2 cm of the right main bronchus. The definitive diagnostic study of choice is a flexible bronchoscopy. A careful bronchoscopic examination documents the site and extent of injury. In fact, diagnoses of tracheobronchial injuries often are delayed, with repairs being performed months or even years after the initial injury. No statistically significant association was found between delay in treatment and successful repair of the injury, with 90% of patients undergoing successful surgical reconstruction more than 1 year after initial injury.
• Pulmonary Injury
A lung contusion represents a bruise of the lung and is usually due to blunt trauma, a lung contusion is usually a combination of alveolar hemorrhage with interstitial hemorrhage and edema. Most patients have minimal respiratory deficit due to the injury. Extensive contusions may result in respiratory difficulty or progress to adult respiratory distress syndrome ARDS, up to 20% of cases of ARDS in the United States have thoracic trauma as an etiology. Mortality rates from ARDS remain approximately 50%.
• Cardiac Injury
The mortality and complication after simple blunt chest injury with blunt cardiac manifestations of ECG or enzyme elevations are extremely low. On the other hand, patients with septal, free wall, valvular, and pericardial tears have mortality rates greater than 50%.
ECG changes and elevation of CK-MB and troponin levels are of limited value because they lack a precise definition of blunt cardiac trauma. And therefore, has not been shown to affect outcome after blunt cardiac injury.
• Great Vessels Injury
Injury to the thoracic great vessels are challenging to manage, most patients die before reaching the hospital, and of those who reach the hospital, most require immediate emergency department thoracotomy. Definitive management of thoracic vascular injuries follows the principles of vascular repair. Many patients survive after repair of acute traumatic aortic transection who would otherwise have died. The overall mortality for patients who arrived at the hospital alive is 32%. Of those who reached the operating room in a presumably stable hemodynamic state, mortality was 21.3% mostly due to hemorrhagic shock and cardiac failure, this mortality ranges from 0% to 54.2% in individual situations. Most deaths occurred in the postoperative period due to either central nervous system injury or organ failure (lung, kidney, liver).
• Diaphragmatic Injury
Mortality and morbidity of patients with acute diaphragmatic injuries differ considerably from patient with a delayed presentation. In the former, multiorgan trauma is usually present and irreversible shock and head injuries are cited most often as the cause of early death (approaching 40%). With strangulated bowel, the mortality rate increase to 80%. When these injuries are isolated and repaired adequately, complications are rare and usually pulmonary in nature. With the chronic type, sepsis, and multisystem organ failure are the usual causes of mortality.
Because of the high mortality associated with missed diaphragmatic injury, some surgeons have supported mandatory laparotomy for all patients with penetrating injury to the lower chest or abdomen. Almost 60% of patients who met the indication for an emergent open operation had a diaphragmatic injury on exploration, laparoscopy also was diagnostic for a diaphragmatic injury in 26% of patients who were stable and asymptomatic. As a result, routine laparoscopy is recommended to evaluate occult diaphragmatic injuries in stable patients with thoracoabdominal penetrating injury who otherwise have no other indication for an open operation.
• Emergency Thoracotomy
Emergency thoracotomy (ET) is a life saving procedure in critically injured patients who present with no detectable pulse or blood pressure following chest injuries. The presence of fully trained doctors in the trauma system is crucial and allows for the performing of on-the-scene ET, which may give a chance for some patients to survive. The incidence of blunt injury in the ET group is almost similar (27-51%) in comparison to the incidence of penetrating injury (26-49%).
A minority of patients however, may benefit from ET. There are reports however, that have suggested the use of closed chest compressions and pericardiocentesis as an alternative. This is may be questionable because external cardiac compression is of limited value in severe cardiac trauma following penetrating injuries, and therapeutic pericardiocentesis is rarely successful because of intrapericardial clotted blood.
In this controversial issue, reports have reviewed that with ET in a prehospital or hospital setting results have yielded in a high survival rate of 18.8% and suggest that ET might be a significant procedure in a well-selected group.
• Video-Assisted Thoracic Surgery
Although the use of VATS in the management of most of the thoracic diseases has gained wide acceptance, its role in the setting of thoracic trauma is not well established. As regards the efficiency of VATS in the management of thoracic trauma. It is recommended that only surgeons with extensive experience in VATS should use it in trauma, because the need for immediate conversion to thoracotomy might emerge. They had a 24% conversion rate.
In conclusion, VATS for specific indications in chest trauma is associated with improved outcomes, decreased morbidity and mortality, and shortened hospital stay. It can be successfully applied in the acute and chronic phase of hemodynamically stable thoracic injuries. It provides diagnostic and therapeutic benefits and thoracic surgeons should be encouraged to incorporate it into their armamentarium and gain experience with its use.