Analysis on short-term outcomes of patients with thoracic trauma at dr. Zainoel Abidin General Hospital in Banda Aceh

Introduction

Thoracic trauma, located on the chest, is an occurrence or incident of an injury that can disturb daily life activities.¹ Trauma will remain one of the main health problems in the world due to its high mortality and morbidity in both developed and developing countries in which the number of deaths in the world caused by trauma reaches around a total of 5.8 million people every year.² There are 53% of deaths caused by trauma that happened where the accident occurred, 7.5% of the cases that happened in the emergency room, and a total of 39.5% that happened in the hospitals,³ of deaths, hospitalizations, and long term disability in the first four decades of life.²

In Indonesia, the incidence of trauma is still high. The Basic Health Research (Riskesdas) of the Ministry of Health of the Republic of Indonesia in 2018 indicates an increasing number of trauma cases, rising from 8.2% to 9.2%. The occurrence of thoracic trauma in the province of Aceh is 4.1%.¹ More than 90% of trauma-related deaths occur in low-income countries, which is attributed to their larger population compared to high-income countries.⁴

Thoracic trauma comprises 20-25% of cases of all trauma cases worldwide. It is the third most common cause of death after abdominal injury and head trauma in polytrauma patients.² According to the ATLS protocol, early diagnosis and management of thoracic trauma cases are very important; treatment in the first hours of trauma is the gold standard, it is associated with a greater probability of reducing morbidity and mortality. Thoracic trauma is classified into open (penetrating) and closed (blunt). According to the type of trauma, lesions can be divided into four groups: lesions on the thoracic wall, lesions of the lungs, mediastinum, and diaphragm. The most common lesions are rib fractures and injury to the heart, aorta, and diaphragm.⁵ This research was conducted at the Zainoel Abidin General Hospital Banda Aceh, the top referral hospital in the Aceh province. This study aims to see what factors can affect the short-term outcome of trauma patients’ thorax at The Zainoel Abidin General Hospital Banda Aceh.

Methods

Results

Research on short-term outcome analysis of thoracic trauma patients at The Zainoel Abidin General Hospital Banda Aceh in the 2019-2020 period recorded 260 patients. During data collection at the Medical Record Installation, 169 medical records were obtained, and 91 data were not found. The obtained data recorded a total of 144 patients experiencing thoracic trauma, but three of them did not meet the inclusion and exclusion criteria of the study. The sample in this study amounted to 141 medical records (Figure 1).

The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an abbreviated injury scale (AIS) score and is allocated to one of six body regions.⁶ The quick Sequential Organ Failure Assessment (qSOFA score) is used to assess organ failure, start or adjust sepsis therapy, refer patients to the ICU, and identify life-threatening infections.⁷

Based on, the number of thoracic trauma patients in males is dominating, namely 101 (71.63%) cases. Furthermore, the majority of the length of stay for thoracic trauma patients was less than 7 days, with an average length of stay of 9 days, where there were 63 (44.68%) cases during 2 years of observation. As many as 58 (41.13%) cases were recorded for 7-14 days, and 20 (14.19%) were recorded for >14 days. Regarding the thoracic trauma type, 138 (97.87%) were blunt, and the blunt trauma was caused by traffic accidents on motorcycle users, which recorded as many as 83 (58.7%) cases. In 3 (2.13), patients experience penetrating trauma, mostly caused by being stabbed with iron (Table 1).

Figure 1. Flowchart depicting patient enrollment, treatment, and outcomes.

MV: Mechanical Ventilation.

Table 2 shows that the majority of thoracic trauma patients do not use a ventilator, which consists of 122 (86.52%) cases, while those who use a ventilator are recorded as 19 (13.48%) cases. Most patients, exactly as many as 18 (12.77%), use less than 96 hours duration, and 1 (0.71%) patient was recorded to use for more than 96 hours duration. There are 139 (98.58%) thoracic trauma patients who had no complications of sepsis, but 2 (1.42%) thoracic trauma patients were diagnosed with sepsis during hospitalization (Table 3). The qSOFA score in the majority of thoracic trauma patients was 0 in 117 (82.98%) cases, followed by 1 in 19 (13.48%) cases and 2 in 5 (3.55%) cases. Moreover, the injury severity score in the majority of thoracic trauma patients was in the <16 (low) group, namely 87 (61.70%) cases, followed by the 16-30 (moderate) group, which was 54 (38.30%) cases.

The majority of patients with thoracic trauma were diagnosed with rib fractures as 42 (29.77%) cases, followed by rib and clavicle fractures in 23 (16.31%) cases, clavicle fractures in 18 (12.77%), pulmonary contusion was recorded in 7 (4.96%) cases, rib fractures with hemothorax in 10 (7.09%) cases, hemothorax and pneumothorax in 5 (3.55%) and 2 (1.42%) cases respectively. In addition, 1 (0.71%) cases of each flail chest and cardiac tamponade (Table 3).

In our study, 16 (11.35%) out of 141 patients only needed conservative treatment, including chest physiotherapy and analgesics. In comparison, 125 (88.65%) patients needed operative treatment where open reduction internal fixation (ORIF) with chest tube insertion was the common modality to treat thoracic trauma victims, followed by thoracotomy and video-assisted thoracic surgery (VATS). In addition, decompression of thoracic vertebrae was found in 1 (0.71%) cases (Table 4).

Discussion

Our study shows the highest incidence of thoracic trauma occurred in patients with male gender. Research conducted by Christoporus et al. stated that the reason for the male gender experiencing chest trauma more often was because the level of activity carried out by men was higher than that of women; male occupations are mostly done outside the home. In addition, men tend to pay less attention to safety when driving a motorized vehicle.⁸ Based on Table 1, the majority of thoracic traumas occur due to blunt objects; the increasing incidence of blunt trauma is caused by an increase in population and high traffic flow. The study of Jigar et al. in India stated that the type of injury a geographical area faces depends on civilization, society, culture and industrialization.⁹ Meanwhile, penetrating trauma is usually determined by the level of crime and violence that occurs in the community in the area itself. Furthermore, the causes of thoracic trauma with the type of blunt trauma are caused by traffic accidents on motorcycle users, which is recorded as many as 83 (58.7%) cases. During the 2015-2019, traffic accidents increased by 4.87% per year. In the report by the National Police Traffic Corps, it is stated that motorcycle accidents still dominate in Indonesia; this is because the majority of Indonesian people use motorcycles. This can occur due to motorcyclists’ non-compliance with traffic signs and speed when driving a motorized vehicle.

The length of stay for chest trauma patients depends on the severity of the trauma and other additional injuries. Many factors affect the length of stays such as the type of injury, complications that occur during treatment, and the treatment in the intensive care unit.¹⁰ The study of Eray et al. said that there was a relationship between oxygen saturation and length of stay, namely the lower the oxygen saturation of trauma patients, the longer the length of stay. In addition, deaths that occur early in treatment are the reason for shorter hospital stays.¹¹ In this study, the length of stay of patients with chest trauma was less than seven days. A study in Sri Lanka said that the presence of flail chest and injury to the trachea was associated in length of stay patients with chest trauma.¹²

According to Table 2, the presence of pulmonary contusions with or without a flail chest is usually associated with a high incidence of ventilator use.¹³ The presence of pulmonary contusions can injure small airways and damage capillaries and epithelial cells. These conditions can cause an increase in pulmonary capillary permeability which will cause alveolar edema. The previous study shows significantly that severe rib fractures were associated with a long mechanical ventilation period. Hence, assessing the extent of rib fractures could estimate the requirement of mechanical ventilation and prolong ICU days.¹⁴ In this study, patients who required the use of a ventilator and had access to it tended to have a high probability of getting a good outcome or living. This is in line with the research conducted by Niloofar et al. in Canada.¹⁵ Moreover, there is a significant relationship between the duration of the ventilator and the short-term outcome of thoracic trauma patients. In this study, patients who did not require a ventilator tended to have a fairly good short-term outcome. Our study reported that 2 out of 141 patients with chest trauma fell into the septic condition. Patients falling into the septic condition is usually caused by open wounds and chest tube insertion. Otherwise, a study in Tanzania revealed that sepsis is the most common complication in chest trauma patients, this difference is caused by the quality of attention provided to patients between the two countries.¹⁶

There was a significant relationship between qSOFA scores and short-term outcomes of thoracic trauma patients. This is in line with the research conducted by Wenjuang et al. in Taiwan in 2021 where the study stated that the higher the qSOFA score of trauma patients, the worse the outcome (Table 2).¹⁷ Furthermore, there is a significant relationship between ISS scores and short-term outcomes of thoracic trauma patients. This is in line with the research conducted by Monafisha et al. in Tanzania which showed that there was a significant relationship between ISS scores and the outcome of thoracic trauma patients.¹⁶ In addition, the study conducted by Sadiye et al. in Turkey also shows the same thing.¹⁸ Based on Table 3, there is a significant relationship between the diagnosis and the short-term outcome of thoracic trauma patients. This is different from the research from Ethiopia in 2020 that stated that there was no significant relationship between the diagnosis and the outcome of thoracic trauma patients. The difference probably because the study only used primary diagnoses of thoracic trauma patients.¹⁹ Meanwhile, a study in Germany, which examined the outcome of thoracic trauma patients, said that rib fractures indicate death at an advanced age and the number of rib fractures correlates with poor outcomes. Bilateral flail chest is associated with increased mortality and injury to intrathoracic vessels and cardiac lacerations are associated with high mortality and prolonged ventilation also causes significant morbidity in chest trauma patients.²⁰ Based on Table 4, there is a significant relationship between management and short-term outcomes of thoracic trauma patients. This is in line with research conducted by Ararso et al. in Ethiopia in 2020 which stated that there was a significant relationship between treatment and outcome of thoracic trauma patients. The study divided the management into conservative and operative which consisted of insertion of a chest tube and thoracotomy.¹⁹ a study conducted by Hafiz in the UK said that surgery performed within the first 48 hours resulted in shorter ICU stays, reduced risk of complications such as pneumonia, shorter hospital stays and shorter use of intensive ventilation overall.²¹ Research conducted by Christian et al in Switzerland stated that the return to work rate for 6 months after chest trauma was higher in the open reduction internal fixation (ORIF) group. Symptoms such as subjective dyspnea, chest pain, and chest stiffness were common in the nonoperative group 6-12 months after the trauma.²²

Based on our result in Table 5, the variable that has a greater influence on the short-term outcome of thoracic trauma patients is the ISS score, in which patients that have a lower ISS score have an 11 times greater chance compared to the patients with the higher ISS score. This is in line with research conducted by Monafisha et al. in Canada where research shows that patients who have a high ISS score have a six times risk of producing a poor outcome.¹⁶ The same thing was also stated by Sadiye et al. In Turkey, where the ISS score is an important prognostic factor in the outcome of thoracic trauma patients, the higher the ISS score, the more severe the trauma.¹⁸

Conclusion

In summary, thoracic trauma is a public health problem among all trauma admissions at Dr. Zainoel Abidin General Hospital. The majority of chest traumas are caused by road traffic accidents especially motorbikes due to the population of motorbike users being still high. Injury severity score is the most influential factor to the short-term outcome of patients with thoracic trauma, where the lower the ISS score, the greater chance of survival compared to a higher score.

Data availability

Data cannot be shared due to ethical and security concerns, nevertheless, a dataset with all the details can be shared with reviewer or readers at reasonable request to corresponding author.

Author's contributions

All authors have read and approved the final manuscript. The requirements for authorship have been met, and each author believes that the manuscript represents honest work.