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Revista do Colégio Brasileiro de Cirurgiões

Print version ISSN 0100-6991On-line version ISSN 1809-4546

Rev. Col. Bras. Cir. vol.44 no.1 Rio de Janeiro Jan./Feb. 2017

http://dx.doi.org/10.1590/0100-69912017001005 

Original Article

Profile of thoracic trauma victims submitted to chest drainage

CESAR AUGUSTO BROSKA JÚNIOR1 

ADRIANE BARBOSA BOTELHO1 

ANDRÉ DE CASTRO LINHARES1 

MARIANA SANTOS DE-OLIVERIA1 

GABRIELA VERONESE1 

CARLOS ROBERTO NAUFEL JÚNIOR1 

LISLAINE CRUZ BATISTA1 

MARIA ANGÉLICA KURPEL DIOGO1 

1 - Curitiba Evangelical University Hospital, General Surgery and Trauma Service, Curitiba, Parana State, Brazil.

ABSTRACT

Objective:

to describe and compare the variables involved in trauma victims undergoing thoracic drainage.

Methods:

we conducted a retrospective, analytical, descriptive, cross-sectional study, with medical records of patients attended at the Trauma Service of the Curitiba Evangelical University Hospital between February 2011 and January 2014.

Results:

there were 488 patients undergoing chest drainage, 84.7% men and 15.3% women, with an average age of 38.2 years. Attendances usually occurred at night, without predominance between open or closed mechanism, gender or age group. The majority of patients with thoracic trauma requiring drainage were diagnosed by anamnesis and physical examination (41.1%) and drained in the emergency room (80.8%). Most of the patients (66.2%) had another associated lesion, mostly some abdominal viscera. Complications were present in 16.6% (81 patients), most of them due to drainage positioning error (9.2%). The mean hospital stay was 15 days and drainage lasted for an average of 8.1 days, with no statistical difference between open and closed trauma. The clinical outcome was discharge in most cases.

Conclusion:

the profile of patients with thoracic trauma is that of young men, attended at night, with some other associated lesion. Although diagnosis and treatment were rapid and most often without the need for complex examinations, the time of drainage, hospitalization and complications were higher than in the literature, which can be explained by the drainage being made at the Emergency Room and the presence of associated injuries.

Keywords: Thoracic Injuries; Drainage; Wounds and Injuries

INTRODUCTION

Trauma in general has been increasing in recent years and is the third leading cause of death, and the first in individuals under 40 years1.

Chest trauma is an important cause of preventable death, especially in young men between the ages of 20 and 30. The injuries are due to auto accidents (particularly motorcycle ones) and intentional injuries, stabbing and gunshot wounds, with variable frequency according to the region studied2-4.

Most thoracic lesions are represented by pneumothorax, hemothorax or hemopneumothorax, and can be resolved with simple procedures performed in the emergency room, such as chest drainage. Few cases (10% to 30%) require thoracotomy5-8.

The present study aims to know the profile of the victims of thoracic trauma who underwent chest drainage at the Curitiba Evangelical University Hospital (HUEC), as well as the complications and treatments given to these patients.

METHODS

We conducted a retrospective, analytical, cross-sectional study through the analysis of medical records of patients suffering from thoracic trauma submitted to pleural drainage attended at the emergency department and admitted to the General Surgery group ward of the Curitiba Evangelical University Hospital (HUEC) between February 2011 and January 2014.

We included in the study patients of both genders, all ages, submitted to closed drainage in water seal, with or without multiple organ traumatisms, with blunt or penetrating thoracic trauma. We excluded the victims of thoracic trauma who died before the surgeon's conduct or who had conservative treatment.

We analyzed the following variables: trauma mechanism, age, gender, associated lesions, approach, clinical outcome (hospital discharge or death), hospitalization time, use of antibiotics and admission diagnosis method. Associated lesions were stratified by body segment and by involvement of parenchymal or hollow organs.

We present the quantitative variables by means, medians, minimums, maximums ​​and standard deviations, and qualitative ones by frequencies and percentages. We used the Student's t test for independent samples for quantitative variables when comparing the patients' groups defined by the type of trauma, open or closed. For the evaluation of the association between the type of trauma with qualitative variables, we applied the Fisher's exact test or the Chi-square test. Values ​​of p<0.05 indicated statistical significance. We analyzed the data using the IBM SPSS Statistics v.20 software.

The project was approved by the Ethics in Research Committee, CAAE 49521615000000103, on 09/24/2015.

RESULTS

The study included 488 patients, 409 (84.7%) being men and 74 (15.3%) women, with a mean age of 38.2 years. There was no predominance of open (n=258; 52.9%) or closed (n=230; 47.1%) trauma. In men, open trauma was more common (n=221; 86.3%) than closed one (n=188, 82.8%) and in women closed trauma (n=39; 17.2%) was more prevalent (n=35; 13.7%), with no statistical difference between groups. We found no relationship between the type of trauma and the patient's age (Table 1). Most of the visits occurred in the early morning (n=164, 33.6%) and at night (n=146, 29.3%). In the open trauma group, most of the occurrences took place during the early morning (n=91, 36.3%) followed by the night (n=66, 22.6%), morning (n=57, 22.1%), and afternoon (n=44, 17.05%). In the victims of closed trauma the attendances occurred predominantly at night (n=77, 33.5%) followed by the early morning (n=73, 31.7%), afternoon (n=42, 18.3%) and morning (n=38, 16.5%), with no statistical difference.

Table1. Comparison between type of trauma and age, hospital stay and drainage time. 

Variable Type of Trauma N Average Standard Deviation Maximum Minimum p value
Age (years) Open 255 34.7 14.4 85 9 <0.001
Closed 256 42.1 16.4 89 13
Hospital stay (days) Open 258 13.8 15 90 2 0.142
Closed 230 16.3 21.8 215 1
Drainage time (days) Open 252 7.8 6.3 35 1 0.233
Closed 224­ 8.4 6 36 1

In the majority of cases, thoracic injury was diagnosed through history and physical examination (n=200, 41.1%) and simple chest radiography (n=155, 31.8%), followed by computed tomography (CT) (n=129, 26.5%). Among the open traumas, anamnesis and physical examination were mostly sufficient for the diagnosis (n=146, 56.8%), followed by the use of radiography (n=76, 29.6%) and CT (n=33, 12.8%). Among the closed traumas, there was a greater need for complementary tests for diagnosis, CT being the main diagnostic medium (n=94, 40.9%), followed by radiography (n=79, 34.3%) and anamnesis and examination (n=54; 23.5%), with statistical difference between the groups (p <0.001).

The majority of cases were drained at the Emergency Room (n=391, 80.8%), the remainder being divided into drains inserted at the Operating Room (n=44, 9.1%), ICU (n=28; 5.8%) and infirmary (n=21; 4.3%), with unilateral drainage in 394 cases (81.7%). The main site of drainage was the Emergency Room for both open (n=198; 77.3%) and closed (n=193, 84.65%) traumas. In the open traumas the second position was occupied by drainages in Operating Room (n=31, 12.1%) followed by infirmary (n=14, 5.5%) and ICU (n=13, 5.1%). In closed traumas the second position was occupied by the ICU (n=15, 6.6%) followed by the Operating Room (n=13, 5.7%) and infirmary (n=7, 3.1%), with statistical difference between the groups (p=0.04). Unilateral drainage was more common in open traumas (n=214, 83.6%) than in closed ones (n=180, 79.6%) and bilateral drainage was more common in closed traumas (n=46, 20, 4%) in relation to the open ones (n=42; 16,4%), with no statistical difference between the groups.

The majority of cases were pneumothorax (n=199, 40.8%) followed by hemopneumothorax (n=189, 38.7%) and hemothorax (n=94, 19.3%). In the open trauma group, the most frequent lesion was hemopneumothorax (n=118, 45.7%) followed by pneumothorax (n=82, 31.8%) and hemothorax (n=58, 22.5%). In the closed trauma group, the most frequent lesion was pneumothorax (n=117, 50.9%) followed by hemopneumothorax (n=71, 30.9%) and hemothorax (n=36, 15.65%), with statistical difference between groups (p<0.01).

Patients were also stratified for presence of abdominal hollow viscus injuries associated with chest trauma, which were more prevalent in the open trauma group (n=40; 15.6%) than in the closed group (n=4; 1.7%) with statistical difference (p<0.001). Most patients had at least one associated lesion (n=323, 66.2%), represented mostly by other abdominal injuries. The stratification of the associated lesions can be observed in table 2.

Table 2 Associated injuries 

Associated Injuries N %
Thorax 102 20.9
Limbs 75 15.4
Traumatic Brain Injury 60 12.3
Liver 52 10.6
Hollow viscera 40 8.2
Spleen 36 7.4
Spinal Cord 19 3.4
Kidney 8 1.6
Pancreas 3 0.6
Other 3 0.6

The mean hospital stay was 15 days (±18.5) and the drainage time was 8.1 days (±6.1), with no statistical difference when the open and closed groups were compared (Table 1). Complications were present in 81 patients (16.6%), being more common in the open group (n=43, 16.7%) than in the closed group (n=38, 16.5%), with no statistical difference. Complications can be observed in table 3.

Table 3 Complications. 

Complication Frequency Percentage
Positioning error 45 56.2
Infection 27 33.8
Fistula 5 6.3
Retained Clot 2 2.5
Persistent Bleeding 1 1.3
Total 80 100

The majority of patients had a good evolution and were discharged (n=401, 82.2%), without statistical difference between open (n=214, 82.9%) and closed (n=187, 81.3%) trauma. In all, 87 patients died (17.8%), with no statistical difference between the open (n=44, 17.1%) and closed (n=43, 18.7%) trauma groups. Victims of closed trauma required more ICU admission (n=98; 42.6%) than those with open trauma (n=79; 30.7%), with statistical difference (p<0.01).

DISCUSSION

Chest trauma is an important cause of morbidity and mortality, which affects the economically active population and results in losses of productive days and damage to the economy and the public health system. It is also a major cause of preventable deaths. It involves young people, mainly men, and its incidence varies according to the region studied and the mechanism of trauma, the penetrating ones in individuals slightly younger (average of 34.7 years) than those victims of closed traumas (average of 38.2 years)4.

The causes are represented mainly by automobile accidents and intentional penetrating injuries. The predominance of the mechanism varies according to the region studied, with intentional penetrating trauma (stabbing and firearms) being a common cause in some Brazilian capitals (Goiânia, Manaus, São Luiz, Curitiba), while in developed countries the closed trauma represents the main cause4,9. We expected a greater incidence of open traumas (of violent origin) in the night and early morning, but we observed no statistical difference between open and closed traumas as a function of the moment of the trauma.

Closed trauma occurs mainly due to traffic accidents, especially motorbikes, followed by run-overs. The fall comes soon after, being an important cause in elders.

Larger thoracic injuries that affect ventilatory mechanics and that need to be recognized and managed immediately during the primary examination include hypertensive pneumothorax, open pneumothorax, flail chest and pulmonary contusion, and massive hemothorax5. The data showed that pneumothorax was the most frequent lesion in our service. Hemopneumothorax was the most frequent finding in open thoracic trauma, whereas pneumothorax was the most frequent in the closed one. These results differ from studies such as that of Souza4, which showed the predominance of hemothorax as an injury in victims of traffic accidents with blunt thoracic trauma.

As stated earlier, most chest traumas are preventable causes of death. With simple, standardized and relatively inexpensive methods, it is possible to diagnose and often treat them in the Emergency Room5,10. The anamnesis and physical examination were sufficient for the diagnosis and consequent drainage in 41.1% of the cases. In the open traumas treated at the HUEC, anamnesis and physical examination were sufficient for diagnosis in 56.6% of the cases. However, when the closed lesions were analyzed, they were only diagnosed in 23.5%. It is a low index, which can be explained by primary care being performed by training general surgery residents and by the occurrence of minor injuries that went unnoticed in primary care and were identified in imaging tests in the secondary evaluation.

In cases where the diagnosis is doubtful, and in which the patient's clinical conditions allow to perform complementary examinations, these are indicated in the secondary examination, the chest radiography being the first choice. In many cases, it is sufficient for diagnosis, indication of treatment and follow-up5,11. This was the second most used diagnostic method in the present study (31.8% of cases). In the case of closed traumas, chest CT was the most requested exam, being used for diagnosis in 40.87% of cases of closed traumatisms. One explanation for this is that tomography allows the early diagnosis of other associated thoracic and abdominal lesions, which could go unnoticed at first. They are present in an expressive number of patients with thoracic traumatism. CT is also more sensitive for thoracic lesions than plain radiography12,13 as well as a more accurate diagnostic method when complications are suspected11.

Associated lesions are present in a significant number of thoracic traumas. In the literature, they are around 36%13, and in our study, 66.2% of the patients had some other lesion. Most were in extremities, cranioencephalic and abdominal. This higher incidence can be justified by the large number of polytrauma patients admitted to the service.

The mean drainage time was eight days and the hospitalization time was 15 days. A similar study performed in Curitiba shows a drainage time of approximately seven days and hospitalization of ten14. Other works show an average of three to five days of hospitalization and five of drainage, with no difference in relation to open and closed traumas4,11,14,15. The longer hospitalization time can be explained by the existence of associated injuries, as well as the presence of drainage complications, which can also increase drainage time.

Chest drainage is a simple procedure but with a considerable number of complications6, varying from drainage position error and subcutaneous insertion to late complications such as empyema2,6. The place the drainages are performed is believed to be associated with the high complicationrate; most of them happen in the Emergency Room, lacking aseptic conditions, which can lead to a higher incidence of infection. Some studies show that drains inserted in the Emergency Room are more likely to require drainage repositioning and, therefore, the chances of infection increase. Some authors claim that drainage by residents has a greater chance of technical failures, with a higher rate of complications6,16,17.

Infections (33.8%) and positioning errors (52.5%) were the main complications found, which can be reduced with drainage in a Operating Room, since in 80.8% of cases drainage was performed in the Emergency Room, where the antisepsis conditions are not ideal. Similar complication rates were found by other authors, with indices around 30%, with those of infectious origin being the most common14. A factor that contributes to the increase of complications is the presence of retained hemothorax, especially when it results from open wounds caused by stabbing injuries in patients over 39 years of age and with drained volume between 300 and 599 ml11. An explanation for this is that wounds by the knives can carry germs into the thoracic cavity and the blood retained serves as a culture medium for infections18.

The mortality rate of 17.8% was slightly higher than those found in two emergency hospitals in São Paulo (8.3% and 9.9%) and one in Goiânia (11%)18,19. The international mortality rates are similar to the latter, not exceeding 10%13,20,21. Other studies performed in Curitiba, however, show a mortality rate similar to ours, of 17.3%14. The mortality discrepancy may be due to the profile of the patients treated in these hospitals, which receive more severe polytrauma patients, with mortality from other non-thoracic injuries. Likewise, the need for ICU admission was also high in a study carried out in Curitiba, reaching 27.5% of the visits14 but still lower than ours, which reached 36.3%, higher in the victims of closed trauma. Comparing the types of trauma, there was no significant difference in the risk of death.

We conclude that victims of thoracic injury submitted to pleural drainage obey the trauma profile of the Brazilian population, being represented by a young male subject, victim of both closed and open trauma. Events usually occur at night, and the diagnosis is made by clinical examination, the drainage being performed at the emergency room. Victims usually have some associated injury, most commonly of abdominal viscera. There was no difference between the victims of open and closed trauma in relation to hospital stay, drainage time or complications, although victims of blunt trauma had a greater need for ICU admission.

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Source of funding: none

Received: October 17, 2016; Accepted: November 03, 2016

Mailing address: Cesar Augusto Broska Júnior E-mail: cesar_broska41@hotmail.com E-mail: cesar_broska41@gmail.com

Conflict of interest: none

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