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The care of a patient who became impaled on a large aluminum pipe is presented. A review of the literature reveals that most patients with a type I injury either do not survive or present with an unpredictable pattern of injury. Preoperative care requires rapid stabilization, assessment, and interventions based on the pattern of injury. Perioperative management may involve multiple surgeons performing simultaneous surgical procedures.

Background: The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis., Methods: A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed., Results: Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred., Conclusion: The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

Background: Recurrent pneumothorax is the most significant complication after discontinuation of thoracostomy tubes. The primary objective of the present study was to determine which method of tube removal, at the end of inspiration or at the end of expiration, is associated with a lesser risk of developing a recurrent pneumothorax. A secondary objective was to identify potential risk factors for developing recurrence., Methods: A prospective study of 102 chest tubes in 69 trauma patients (1.5 tubes per patient) randomly assigned to removal at the end of inspiration (n = 52) or the end of expiration (n = 50)., Results: Recurrent pneumothorax or enlargement of a small but stable pneumothorax was observed after the removal of four chest tubes in the end-inspiration group (8%) and after discontinuation of three chest tubes (6%) in the end-expiration group (p = 1.0). Of those, only two tubes in the end-inspiration group and 1 tube in the end-expiration group required repeat closed thoracostomy. Multiple factors were analyzed that did not adversely affect outcome. These included patient age, Injury Severity Score, Revised Trauma Score, mechanism of injury, hemothorax, thoracotomy, thoracostomy, previous lung disease, chest tube duration, the presence of more than one thoracostomy tube in the same hemithorax, or a small (but stable) pneumothorax at the time of tube removal., Conclusions: Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post-removal pneumothorax. Both methods are equally safe.

Objective: To evaluate the interest of a grid and the experience of the interpreter to interpretate the chest radiographs (CRs) of patients with thoracic trauma, the reference is the helicoidal computed tomography (HCT)., Study Design: Prospective observational study., Material: CRs and HCT of 50 thorax trauma patients., Method: CRs were analysed without a grid (L) and results were compared with those obtained in an anterior study with a grid (G). The interpreter were residents in anaesthesiology (DESAR; G: n = 6/L: n = 4), residents in radiology (DESR; G: n = 3/L: n = 5), senior anaesthesiologists (MAR; G: n = 5/L: n = 4), and senior radiologists (MR; G: n = 3/L: n = 5). The reference was the HCT. The lectors were compared., Results: The interpretation of the CRs was neither influenced by the experience and the specialty of the lector nor by the use of a grid. Perhaps the formation is sufficient for the anaesthesiologists to evaluate the essential lesions in the trauma patient and treat them.

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.

Background: The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma., Methods: We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998., Results: During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case., Conclusion: Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.

The purpose of a fracture classification is to help the surgeon to choose an appropriate method of treatment for each and every fracture occurring in a particular anatomical region. The classification tool should not only suggest a method of treatment, it should also provide the surgeon with a reasonably precise estimation of the outcome of that treatment. But to use a classification before its workability has been proved is inappropriate and can lead to confusion and more conflicting results. Any classification system should be proved to be a workable tool before it is used in a discriminatory or predictive manner. The radiographs of fourteen fractures of the lumbar spine were used to assess the interobserver reliability of the AO classification system. The radiographs and CT scans were reviewed in twenty-two hospitals experienced with spinal trauma. The mean interobserver agreement for all fourteen cases was found to be 67% (41-91%), when only the three main types (A, B, C) were used. The corresponding kappa value of the interobserver reliability showed a coefficient of 0.33 (range, 0.30 to 0.35). The reliability decreased by increasing the categories. For some injuries the interobserver reliability was found to be over 90% and also for the recommended therapeutic procedure there was an acceptable agreement. But the decision between an posterior approach alone or an additionally anterior procedure seems to be the most important question in treatment of spinal injuries at that time.

Objectives: To determine the distribution of injuries in the eventing discipline of equestrian sports and the effectiveness of the protective equipment worn., Methods: Data on all injuries sustained in the cross country phase over fixed obstacles were collected from 54 days of competition from 1992 to 1997. This involved 16,940 rides., Results: Data on a total of 193 injuries were collected, which included two deaths. This represents an injury rate of 1.1%. Head and facial injuries represented the largest group (31%), with one third of these requiring treatment in hospital. All riders were wearing protective helmets and body protectors., Conclusions: Eventing is one of the most dangerous equestrian sports. Improved protective equipment, which is mandatory for 1999, should reduce the severity of these injuries.

Reporting the case of a short-range severe thoracic shotgun injury the differentiated management of this trauma is discussed. Indication for operative exploration under emergency conditions is hemorrhagic shock, perforation of esophagus/stomach and pericardial tamponade. Even under a toxicological point of view there is no indication for emergency revisions.

Background: Plastic bullets were introduced to Northern Ireland for riot-control purposes in 1973. Their use has been controversial, with a number of fatalities. In the week beginning July 7, 1996, some 8,000 plastic bullets were fired during widespread rioting., Methods: Details of injuries attributed to plastic bullets were obtained retrospectively from patient notes for the period July 8 to 14, 1996, in six hospitals. A total of 172 injuries in 155 patients were recorded., Results: Nineteen percent of injuries were to the face/head/neck, 20% were to the chest or abdomen, and 61% were to the limbs. Abbreviated Injury Scale scores ranged from I to 3. Forty-two patients were admitted for hospitalization, three to intensive care units. No fatalities occurred., Conclusion: Plastic bullet impact to the abdomen or above may cause life-threatening injuries. Below this site, major trauma is unlikely.

Chest trauma can range from broken ribs and knife wounds to collapsed lungs and bruised hearts. This detailed discussion of mechanism of injury, assessment findings, and treatment strategies will help you identify problems and increase your patients' chances for a quick and successful recovery.

Objective: Increasingly powerful nonpowder firearms or air guns are frequently given to children as toys. We undertook the present study to evaluate the injuries caused by these firearms, based on the concern that they are capable of inflicting serious trauma., Design: Descriptive, retrospective chart review., Setting: Urban level I pediatric trauma center., Participants: The study included all children with injuries secondary to air guns who were admitted between July 1988 and March 1995., Main Outcome Measures: Type of weapon, circumstances of injury, anatomic location of injury, injury severity, surgeries performed, morbidity., Interventions: None., Results: There were 42 admissions with a mean hospital stay of seven days (range 1 to 136 days). The average age was 10 years (range 1 to 23 years) with a median age of 11 years. There were 35 boys and 7 girls. Twenty-nine of the 42 injuries were caused by a family member or friend and five were self-inflicted. The mean injury severity score was 8.3. While there were no fatalities, 21 children (50%) underwent operative procedures for their injuries. Ten of the injuries were potentially lethal, of which seven were due to the "pump" action air gun. Sixteen patients had serious long-term disability as a result of their injuries., Conclusion: Air guns can cause a variety of serious injuries, often requiring operative intervention. The long-term morbidity from some of these injuries is significant. Both parents and physicians should be aware that nonpowder guns are not toys, but weapons capable of inflicting serious trauma. The evaluation and treatment of air gun injuries should be similar to that currently used for powder weapon injuries. Recommendations for evaluation and treatment are made.

Objective: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients., Patients and Methods: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center., Results: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group., Conclusions: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

It is generally accepted that the presence of thoracic skeletal injuries has a predictive value for acute traumatic aortic tear (ATAT). The purpose of this study is to objectively assess the validity of that premise. The initial chest radiographs of 548 patients who underwent aortic angiography for suspected ATAT were reviewed for thoracic skeletal injuries. The incidence of thoracic skeletal injuries was compared between patients with and without angiographically confirmed ATAT. Rib fracture is the only thoracic skeletal injury whose incidence is statistically significantly higher in patients with ATAT (36 of 62, 58.1%) than in those without (207 of 486, 42.6%) (p = 0.0209). The positive predictive value of rib fractures in evaluating ATAT, however, is 14.8%, a rate similar to the incidence of ATAT at most trauma centers, and the specificity is 57.4%. The second most common finding in patients with ATAT, the absence of thoracic skeletal injury, is not statistically significantly different between patients with ATAT (24 of 62, 38.7%) and those without (220 of 486, 45.3%) (p = 0.3279). We conclude that (1) there is no clinically relevant correlation between thoracic skeletal injuries and ATAT, and (2) selection of patients requiring thoracic aortography must be based on appropriate mechanism of injury and radiographic evidence of mediastinal hematoma.

A retrospective review of the medical records of blunt trauma patients with sternal fracture admitted to a level 1 trauma center from June 1990 to June 1993 was undertaken to determine the relationship between sternal fractures and clinically significant myocardial injury, and to assess the usefulness of cardiac evaluation and monitoring in these patients. Of 33 patients with sternal fracture, 31 were in motor vehicle crashes and 2 were pedestrians struck. All had Glasgow Coma Scale score = 15. No patient had a severe, life-threatening, associated injury (Abbreviated Injury Score of >3). No electrocardiogram or echocardiogram showed evidence of acute injury or ischemia. No arrhythmias requiring treatment were noted. No CPK-MB fraction was >5%. These results show that sternal fracture is not a marker for clinically significant myocardial injury. The management of sternal fracture patients should be directed toward the treatment of associated injuries.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.

Ventilation impairment, due to ineffective elimination of the mucous-hemorrhagic content from the tracheobronchial tree (TBT), obstructs the upper airways with the ensuing ventilation reduction giving rise to atelectases and progressive alveolar block. There is evidence of transudation and exudation into the pulmonary pathways and pleural cavity. A series of 276 patients presenting closed chest trauma are subjected to fibrobronchoscopy (FBS) and follow-up study. In 92 of them bronchoscopy is performed 2 to 15 times per patient, accordingly: in 75-twice, in 10-five times and in 15-twice. One-hundred twenty-nine of the total of 276 cases under study are on mechanical ventilation. In 56 instances FBS is carried out through a tracheostomy cannula, in 73-by intubation, in 18-through the mouth, and in two--through the nose. Based on the obtained results, algorithms for assessment of the rheological properties of tracheobronchial secretion and degree of impairment of TBT drainage function during emergency FBS in closed chest injuries are worked out, having an essential practical bearing on the diagnostic and therapeutic approach to closed thoracic trauma.

Objective: The aim of this study was to identify risk factors and to describe epidemiological patterns for early-(EOB) and late-onset bacteremias (LOB) after trauma., Design: A prospective study conducted on 141 consecutive trauma patients., Setting: A general intensive care unit (ICU) of a university hospital., Patients: All multiple trauma patients admitted to our general intensive care unit (ICU) from December 1990 to May 1992 were prospectively enrolled in the study. The following information was collected for each patient and recorded in a computer database: demography, severity of trauma according to the Abbreviated Injury Scale (AIS), severity of coma according to the Glasgow Coma Scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and abdominal trauma, use of mechanical ventilation, and placement of central venous catheters. Bacteremias were defined as EOB when onset occurred within 96 h after trauma, and as LOB when appearing after 96 h from trauma., Results: Thirty-seven patients developed bacteremia during their ICU stay (26%): 11 (29.7%) EOB and 26 (70.3%) LOB. Gram-positive cocci were isolated more frequently in EOB than in LOB (chi 2 = 4.1, P = 0.04). The risk of EOB was significantly increased by the presence of pulmonary contusion [relative risk (RR) 15.0; confidence interval (CI) 1.99-113.25], pneumonia before the onset of bacteremia (RR 3.56; CI 1.17-10.69), AIS score greater than 32 and an abdominal injury score greater than 9 (RR 3.11; CI 1.02-9.49), while intravascular catheters and mechanical ventilation did not represent risk factors for EOB. LOB had a very different pattern and their risk was significantly increased by exposure to intravascular catheters (RR 4.96; CI 1.23-19.94) and to mechanical ventilation lasting more than 7 days (RR 3.6; CI 1.6-8.1)., Conclusions: Scoring with the AIS of the abdominal and thoracic trauma at admission to the ICU appears a useful tool for identifying trauma patients at increased risk of EOB. A rigorous policy of catheter placement and maintenance as a means of reducing late bacteremias in trauma patients is essential.

January, 1992, to September, 1994, a hundred and seventy-eight blunt chest trauma patients were examined with plain chest films and detailed rib studies. The patients were subdivided into three groups according to: a) the presence/absence of rib fractures correlated with clinical data; b) the depiction of rib fractures and/or thoracic complications; c) treatment customization in the presence/absence of rib fractures. In our series of patients the clinical data and the presence of rib fractures were poorly correlated. The detection rates of minor and major complications were also investigated on plain chest films and detailed rib studies. Plain chest films most frequently depicted the complications requiring conservative or surgical management and gave the indication for further imaging investigations. The detailed rib studies of the involved hemithorax yielded no further information useful to therapy except in few cases: and should therefore be limited to the cases exhibiting complications on chest films, which may benefit from surgical fixation. The accurate study of rib fractures is paramount in the cases where legal action may be undertaken.

The effectiveness of air bags, drivers-side and passenger-side, as an additional passive safety system in motor vehicles was tested in a collective study in which 47 trauma centers in Germany participated. The inquiry was answered by 80% of 181 hospitals. The evaluation of a total of 119 air bag-protected patients involved in accidents, who were treated in German trauma centers in the year 1993 shows predominant minor injuries on the head-, cervical- and thorax-region. Some patients had superficial injuries caused by air bag in their face and chest area, such as abrasions and contusions. It is notable, that a large number of patients continue to suffer severe injuries (AIS 3+) in their lower extremities. The trend of the industry to equip more and more vehicles with air bags must be sustained. According to manufacturer statements, in 1994 already more than 60% of all mass produced vehicles in Germany will be provided with this modern passive safety system.

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS < 8 underwent surgical intervention, whereas only two of the eight patients with a PTS > or = 8 needed surgery (P < 0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.

Based on experimental and clinical data the authors propose a classification of closed thoracic traumas which allow to form relatively similar groups among patients with closed thoracic traumas having orientation of the leading pathogenetic factor. The proposed classification allows to form rational curative programs as early as at the prehospital and early hospital stages.

From 1981 to 1989, 323 patients whose diagnoses resulted from ski injuries were emergently admitted to a Class 1 Trauma Hospital. Of this group, 107 (33%) were injured in skier-tree collisions. This tree collision group (TC group) was compared with a group that did not hit a tree (non-tree-collision group or NTC group). The average age of the TC group was 26 years, compared with 31 years in the NTC group. The Revised Trauma Score (RTS) was recorded for each patient. The TC group's average trauma score was 7.205, compared with 7.7395 for the NTC group. The Injury Severity Score (ISS) was also recorded. The TC group's ISS averaged 14.7, compared with 9.1 for the NTC group. Both of these scores demonstrated statistical significance. Certain injuries such as skull fractures, head injuries, pelvic fractures, and chest injuries (including rib fractures, pneumothoraces, and pulmonary contusions) were more common in the TC group. Tibia fractures were more common in the NTC group. Femur fractures and upper extremity fractures were evenly distributed between the two groups. Seven deaths were recorded in the TC group and five deaths occurred in the NTC group.

Penetrating chest trauma causes a broad spectrum of injury that requires a variety of diagnostic and resuscitative skills. Prompt resuscitation and decisive action are mandatory for patients who present in extremis, whereas a thorough diagnostic evaluation and appropriate observation are indicated in less compelling circumstances. Clinical skill and judgment along with plain radiographs provide the basis for treatment in most cases. More sophisticated imaging techniques, with the exception of angiography, are of limited value. A systematic approach based on wound location, be it central, peripheral, or proximate to the diaphragm, should result in timely resuscitation and sound diagnostic evaluation.

This study was designed to examine the results of emergency room resuscitative thoracotomy (ERRT) and to formulate cost-effective indications for this procedure. A retrospective study was performed of 28 patients who had ERRT at St. Elizabeth Hospital Medical Center, Youngstown, Ohio, during the 4 years from July 1985 through June 1989. The prognostic factors analyzed included mechanism and site of injury, signs of life (SOL), vital signs (VS), age, gender, and prehospital care. The overall survival rate of ERRT was 7% (2 of 28 patients). The survival rate was 18% (2 of 11 patients) with penetrating trauma, and 0% (none of 17 patients) with blunt trauma. The best survival rate was 66% in the subgroup of patients with penetrating trauma and SOL present at the scene and in the emergency room (ER), (two of three patients). Our observations were combined with those of 23 studies from the literature involving 2294 trauma patients who had ERRT. Using meta-analysis, the survival rate was 11% overall. Improved survival was noted for patients with penetrating trauma compared with patients with blunt trauma (14% vs. 2%, p < 0.01). There were no survivors in the group of patients with no SOL at the scene, and there were no neurologically intact survivors among blunt trauma patients with no SOL upon arrival at the ER. An algorithm based on mechanism of injury and presence or absence of SOL at the scene and in the ER is proposed. This algorithm would decrease the number of ERRTs performed by 41% without decreasing the number of neurologically intact survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

We analyzed the records of 4,169 victims of traffic collisions fatally injured during the period 1972 to 1985. Chest injuries were recorded as the main cause of death in 1,121 victims; 207 of them had worn a seatbelt. Rupture of the heart was found at autopsy in 75 of these seatbelt wearers. Exact information on the location and the size of the heart rupture was available in 47 cases. For a control group, we analyzed 47 randomly chosen unbelted victims who had sustained a fatal heart rupture in comparable collisions. The site of cardiac injury was a ventricle in 75.5%. In frontal impact collisions the mechanism leading to heart rupture is usually crushing against the steering wheel, even in seatbelt wearers. Most of the victims had multiple injuries, and only serious collisions, often with a heavier vehicle, led to fatal heart rupture.

The study presented 596 cases with chest injuries, experienced for 4 years in our trauma and critical care center. Cases with chest injuries account for approximately 40% of all traumatized patients. Cases dead on arrival (DOA) show more significant frequency (87% of all traumatized DOA patients). To grasp the significance and the severity of chest injuries, we designed a new classification by the site where abnormality exists; 1) the chest wall, 2) the pleural cavity, 3) the airway, 4) the mediastinum, 5) the intrapericardial space, and 6) cardiac function. An application of the classification may clearly identify the initial direction for the treatment of chest injuries, including some examination which should be given priority. It is also suspected that a more exact decision making should be possible by an utilization of the classification.

The authors observed and helped 157 patients with multiple trauma of the chest. Trauma shock was observed in 97 of them. A clinical classification of such injuries is proposed. Main combinations of injuries of internal organs have been found. Surgical tactics is considered.

The primary survey of a trauma victim always begins with the ABCs used in resuscitation. Chest trauma compromises the normal physiology of respiration and circulation. Although some chest injuries are overt, some are not. The mechanism of injury is important for increasing the degree of suspicion used to identify covert injuries. The most lethal injuries include tension pneumothorax, sucking chest wound, massive hemothorax, flail chest, and cardiac tamponade. Cardiac and aortic ruptures often cause death before the victim enters the health care system. Potentially lethal injuries include myocardial and pulmonary contusion, tracheobronchial disruption, and esophageal disruption. Trauma victims present with many combinations of chest injuries. The care of these patients is very complex. Nursing diagnoses guide the care of chest trauma patients and can include impaired gas exchange, alteration in cardiac output, and altered breathing pattern. The goal of treatment is to restore and maintain stable hemodynamics with adequate respirations and circulation allowing definitive treatment for a positive patient outcome.

The thoracic trauma index (TTI) provides an indication of the severity of injuries received by motor vehicle occupants in side-impact collision environments. The index was derived from results on two sets of cadaver tests. Using a variety of statistical and numerical methods, the authors reanalyzed the data from these 80+ cadaver tests to construct a better measure of injury than TTI. Indices generated by these analyses were compared with TTI using the following quantitative measures: monotonicity, overlap, percentage correct, and sensitivity. The values of these measures are broadly similar for all indices and none of the new indices consistently performs better than TTI. This suggests that TTI is as good a predictor of injury as any of the several alternative models created.

Since a controversy exists over whether patients with truncal shotgun wounds should have selective or mandatory exploration, we reviewed the records of 1,222 patients with truncal missle wounds treated over a six year period at our institution. Based upon a detailed review of 42 of these patients, who had sustained shotgun wounds, we believe that not all patients with truncal shotgun wounds require mandatory surgical exploration. That, in fact, a subgroup of patients can be identified who can be safely managed nonoperatively, based upon the pattern of the injury and the clinical status of the patient at the time of arrival to the emergency room.

A radiological check list in trauma of the thorax is presented that is oriented by means of topographic locations (thoracic wall, pleura, lung, mediastinal organs). Focus is on the specific features of lung contusion and lesions of the mediastinal organs with special reference to modern examination methods.

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.

On the basis of their experience with the treatment of 166 patients with injuries of the chest and abdomen the authors mark out simultaneous thoracoabdominal and abdomino-thoracal wounds. Among thoracoabdominal wounds there are trans- and extrapleural wounds with injuries of the central and peripheral portions of the diaphragm. Abdomino-thoracal wounds may be trans- and extraperitoneal and can penetrate into the pleural, pericardial and mediastinal cavities. This type of associated wounds of the chest and abdomen is most dangerous since in one third of the patients it includes wounds of the heart which are difficult for diagnosis.

Most reports of penetrating chest wounds include all regions of the thoracic wall. Recent studies of abdominal wounds stratified by entrance site have demonstrated significant differences in injury pattern that influence initial assessment and management. This is an analysis of 135 consecutive patients admitted to the Denver General Hospital with penetrating injuries to the posterior chest, done in an effort to elucidate operative indications. Fifteen of these patients required emergency department (ED) thoracotomy and were excluded from the study. In the remaining 120 patients, mechanism was gunshot (GSW) in 20% and stab wound (SW) in 80%; 89% were men, and the mean age was 26 years. For analysis, the posterior chest was further divided into upper and lower at the inferior tip of the scapula line. Overall, 28 patients (23%) with posterior penetrating chest wounds required early surgical intervention; 38% following a GSW compared to 20% due to a SW. Only 9 patients (8%) required thoracotomy while 19 (15%) underwent laparotomy. The most frequent indication for thoracotomy was persistent chest hemorrhage, and for laparotomy, positive diagnostic peritoneal lavage.

In patients with nonpenetrating thoracic trauma, the rib fractures and other chest wall lesions may distract the physician from dangerous internal injuries in the chest or abdomen which may not be noted unless looked for very carefully. Early vigorous correction of any ventilatory problem is essential, particularly if there is any evidence of impaired tissue perfusion. Shock is frequently due to extrathoracic injuries, particularly intraabdominal bleeding. The flail associated with multiple rib fractures may seem mild initially, but severe underlying pulponary contusion and/or associated extrathoracic injuries make early ventilatory assistance extremely important. Rupture of the thoracic aorta should be suspected in rapid deceleration injuries, but is often not considered unless there is widening of the superior mediastinum on hte chest x-ray. Aortography to confirm the aortic tear should be done if time permits, and early repair of the injury provides the best results.