The Pattern and Outcome of Chest Injuries in South West Nigeria

Original Article The AnnAls of AfricAn surgery | www.sskenya.org

Author: Ogunrombi A.B. 1 FWACS, MSc(Med)CTS, Onakpoya1 U.U. FWACS, Ekrikpo U.2 MBBS, MSc(Med), Adesunkanmi A.K. 1 FWACS, FICS, Adejare I.E. 1 MBBS Affiliations: 1- Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife 2- Department of Medicine, University of Uyo Teaching Hospital, Uyo, Nigeria Correspondence: Akinwumi B. Ogunrombi Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, 220005, Nigeria. +2348062279218 Email- [email protected]

Abstract Objective: The pattern and management outcome of chest injuries deaths (56%) in those with severe ISS. Majority of patients (51.8%) presenting to our tertiary university hospital located in a semi-urban required only analgesics, while additional closed tube thoracostomy population in the South West of Nigeria, has not been documented drainage was necessary (41.8%) in the others who suffered blunt previously. We therefore sought to identify factors that may contribute trauma. Thoracotomy was indicated for only 5 (4.5%) penetrating to mortality. injuries. There is a rising trend towards penetrating gunshot injuries, Method: We analyzed 114 patients presenting to the Accident and with mortality increasing with age (p=0.03) and severity of associated Emergency Unit with chest trauma, prospectively entered into a data injuries (ISS) (p=0.003). base over a two year period. Conclusion: Majority of the patients required only minimal interven- Results: Chest trauma accounted for 6% of all trauma admissions tion with chest drainage or analgesics, with low mortality. Increasing with a male preponderance (M:F = 3.6:1). Rib fractures were the most age and severity of injury contributed significantly to mortality. Initia- common injury (46.3%) while limb fractures were the most common tion of care for chest trauma victims is still delayed in our centre. associated injury (35.8%). Associated head injury accounted for most

Introduction Patients and Methods Trauma is a leading cause of morbidity and death in de- The Obafemi Awolowo University Teaching Hospital, Ile- veloping countries with thoracic trauma contributing sig- Ife, (OAUTH), is a major trauma referral center in South nificantly to these figures especially where infrastructure Western Nigeria with compliment of specialists in all ma- and personnel are ill equipped to cater for these critically jor surgical and other disciplines. The Accident and Emer- ill patients. It is estimated that death from unintentional gency Unit of the hospital is a 15- bedded ward staffed trauma is on the increase in developing countries though by trauma doctors and nurses overseen by a trauma con- not as significantly as that from infectious diseases like sultant, while a 6-bedded Intensive Care Unit caters for diarrhoea and malaria, while it is on the decrease in in- the critically ill. The hospital is strategically positioned in dustrialized countries (1). Previous reports on incidence a network of highways linking major cities in the South of blunt versus penetrating injury from Nigeria have been West and other parts of Nigeria. conflicting depending on the urbanisation of the region All patients with blunt or penetrating chest trauma as well as prevailing circumstances of peace or regional presenting to the Accident and Emergency Unit of the armed violence which occur sporadically (2-3). OAUTH, Ile-Ife and having had appropriate chest radio- We have examined the spectrum of these civilian chest in- graphs, were prospectively entered into a database which juries during times of peace to determine the incidences was collected over a period of two years (May 2008 – of blunt and penetrating injuries and the outcomes of April 2010). All patients who did not require chest radio- our management strategies, evaluating the emergency graphs after careful physical examination were excluded room initiation of care for these critically ill patients to from the analyses. determine factors that may contribute to mortality and The demographics, mechanism of injury, time to presen- ascertain whether our current setup is achieving results tation, vital signs on admission, injury sustained, Injury comparable with other trauma centers. Severity Score (ISS) as well as management instituted were evaluated.

The AnnAls of AfricAn surgery • Volume 9 • July 201215 78 The ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 The AnnAls of AfricAn surgery | www.sskenya.org Original Article The ANNALS of AFRICAN SURGERY | www.sskenya.org OriginalOriginal article a rticle

The PatternTh ane dP atteOutcomrn aned o Outcomf Chest eInjurie of Chess int InjurieSouth sW iesn Soutt Nigheria Wes t Nigeria Ogunrombi A.B.Ogunromb, Onakpoyi A.B.a U.U., Onakpoy, Ekrikpao U.U.U., Adesunkanm, Ekrikpo U., iAdesunkanm A.K., Adejarei A.K.I.E. , Adejare I.E.

ContinuousContinuou variables wser veariable summarizes were dsummarize using meands usin andg means injurand y than injurthe ydri thavern o fth ae budrisv e(p=0.r of a0 2)bu. sSea (p=0.t bel0t2) usage. Sea t belt usage The Pattern and Outcome of Chest Injuries in standard deviationstandarsd odeviationr medianss oanr dmedian inter-quartils and intere ranges-quartil e rangeswas low at 8.3wa%s lowitw ha tonl 8.3y% 36 wit% ho fonl driyv er36s% usin of gdri seavert sbelts usin g seat belts South West Nigeria (IQR) for th(IQRe highl) foy r skethew highled variabley skews e dan vdariable analyzes and dus analyze- d a tus th- e time oaft ththee accident.time of th e accident. ing two-samplinge ttw-teso-tsampl or Wilcoxoe t-testn o rrank Wilcoxo-sum ntest rank. Discrete-sum test . DiscreteThe most commoThe mosn injurt commoy weren ri injurb fracturey weres ri(46.3%b fracture) whiles (46.3% ) while

variables wervariablee summarizes were dsummarize as countsd anasd count percentagess and percentages49 (44.6% ) 4ha9 d(44.6% hemothora) had x hemothora and 34 (3x0.9% and ) 3presented4 (30.9% ) presented Author: Ogunrombi A.B. 1 FWACS, MSc(Med)CTS, Onakpoya1 U.U. FWACS, Ekrikpo U.2 MBBS, MSc(Med), Adesunkanmi and compareandd usincompareg Chi-dsquar usinge tesChit -osquarr Fishere tes’st exacor Fishert test ’s exact wittesth pneumothorawith pneumothorax both necessitatinx both gnecessitatin chest drainagg chese. t drainage. A.K. 1 FWACS, FICS, Adejare I.E. 1 MBBS Affiliations: 1- Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife 2- Department of Medicine, University of Uyo Teaching Hospital, Uyo, Nigeria Correspondence: Akinwumi B. as appropriatase .appropriat A multivariate. Ae multi logistivariatc regressioe logistinc modelregressio n modelThe most commoThe mosn extrathoracit common extrathoracic injuries werc injuriee limbs frac wer-e limb frac- Ogunrombi Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, 220005, Nigeria. was used to widentifas useyd factorto identifs thayt arfactore independentls that are independently associ- y associture-s in 29 ture(35.8%s in )2 an9 d(35.8% head )injur andy hea in d2 4 injur (29.6%y in ) 2pa4 -(29.6% ) pa- +2348062279218 Email- [email protected] ated with mortalitated wity.h P -mortalitvalues lesy. sP -thavaluen 0.s 0les5 sw thaeren consid 0.05 w- ere considtient- s. Abdominatients.l Abdominainjuries werl einjurie seen si nw 8er (9.9%e seen) ipatientn 8 (9.9%s. ) patients. ered statisticallereyd significantstatistically. Thsignificante data w. aThs analyzee data dw ausings analyze d usingThe medianTh ISeS mediascore wn aISs S9 scor(interquartile was 9 (interquartile range 4 – e18). rang e 4 – 18). Abstract Stata versionStat 10.a Statacorpversion 1,0 .T exaStatacorps, USA., Texas, USA. Figure 2 showFigurs the e2 proportioshows then proportioof individualn ofs individualwith ISS s with ISS This study wThias sappr studoyv ewda sb yappr the oHospitalsved by th’ e EthicaHospitalsl Com’ Ethica- l Comscor-e less thascorn 16e ,les 16s tha– 2n4 16an,d 1greate6 – 24r thaandn greate24. Our rtha studyn 24 . Our study Objective: The pattern and management outcome of chest injuries deaths (56%) in those with severe ISS. Majority of patients (51.8%) presenting to our tertiary university hospital located in a semi-urban required only analgesics, while additional closed tube thoracostomy mittee. mittee. showed a mediashowend IS aS mediaof 27 n(IQ ISRS o23.5f 27- 36(IQ) Rin 23.5those-36 who) in those who population in the South West of Nigeria, has not been documented drainage was necessary (41.8%) in the others who suffered blunt died and a mediadied ann dIS aS mediaof 9 (IQn RIS S4 -o16f 9) (IQin thosR 4e-16 wh) oin surthos- e who sur- previously. We therefore sought to identify factors that may contribute trauma. Thoracotomy was indicated for only 5 (4.5%) penetrating ResultsResults vived. vived. to mortality. injuries. There is a rising trend towards penetrating gunshot injuries,

Method: We analyzed 114 patients presenting to the Accident and with mortality increasing with age (p=0.03) and severity of associated Emergency Unit with chest trauma, prospectively entered into a data injuries (ISS) (p=0.003). DemographicsDemographics TreatmentTreatment base over a two year period. Conclusion: Majority of the patients required only minimal interven- Out of a totaOul to fo 184f a 7tota patientl of 184s admitte7 patientd tso admittethe Accidentd to th e AccidentFifty three (48.1%Fifty thre) hae d(48.1% closed) tubhade closethoracostod tubem thoracostoy drain- my drain- Results: Chest trauma accounted for 6% of all trauma admissions tion with chest drainage or analgesics, with low mortality. Increasing and Emergencandy UniEmergenct folloywin Unig ttraum followina during traumg thea studyduring the studyage (CTTD)ag aes (parCTTDt of) theias parr treatment of theitr wit treatmenh 26.4%t wit inh- 26.4% in- age and severity of injury contributed significantly to mortality. Initia- with a male preponderance (M:F = 3.6:1). Rib fractures were the most period, 114 period (6.2%, ) 1 1patient4 (6.2%s ha) dpatient chests injuriehad chess. Theret injurie s. Thereserte d on theserte rightd ,o n14.6 the% right on ,th 14.6e lef%t anond th6.4e %lef bilateral.t and 6.4 % bilateral. common injury (46.3%) while limb fractures were the most common tion of care for chest trauma victims is still delayed in our centre. were 89 (78.1%were )8 male9 (78.1%s and) 2male5 (2s1.9% and ) 2female5 (21.9%s (ratio) female s (ratio91.67 % of 9thos1.67e% tha otf diethosd e ha thad t a dieCTTd Dha dperforme a CTTDd onperforme d on associated injury (35.8%). Associated head injury accounted for most 3.6:1) with 3.6:1mean) agwiteh o fmea 40.n4 ag±15.e o8f y40.ear4s .±15. The8 mea yearn s .age Th e mean theagem (p= 0.0the0m2) . (pInsertio= 0.00n2) o. fInsertio CTTD,n base of dC TTD on ,positi basedv e on positive

for the femalfoer patientthe femals wea spatient 38.6±14.s w3as y 38.6±14.ears while3 ythaeart sof whil e thathoracocentesit of thoracocentesis alone withous alont eprio withour chestt prioradiograpr chesht yradiograp hy the males wthase 40.9±16. males w2a sy 40.9±16.ears. Twent2 year sixs .(22.8% Twenty) sioxf the(22.8% ) ofoccurre the d in occurreonly 3d (2.7% in onl) ypatient 3 (2.7%s. Supporti) patientves . chesSupportit ra-v e chest ra- Introduction Patients and Methods patients werpatiente traderss ;w 2er6e (22.8%traders; ) 2w6er (22.8%e office) wworkerere offics, 2e1 workersdiograph, 21 s wdiographere availabls weer ei n av thailable othere isn (97.3%the other) sbefore (97.3% ) before Trauma is a leading cause of morbidity and death in de- The Obafemi Awolowo University Teaching Hospital, Ile- (18.4%) wer(18.4%e artisan) sw, er 1e5 artisan (13.2%s, )1 uni5 (13.2%versity )student universits, y studentchess, t drainagchese. t drainage. veloping countries with thoracic trauma contributing sig- Ife, (OAUTH), is a major trauma referral center in South 11 (9.7%) w1er1 e(9.7% driver)s wanerde dri9 (7.9%vers an) dw er9 e(7.9% farmer) sw. erTheree farmer s. ThereThoracoto mThoracotoy was necessarmy wya sin necessar only 5 y(4.5% in onl) ypatient 5 (4.5%s, 3) patients, 3 infrastructure Western Nigeria with compliment of specialists in all ma- nificantly to these figures especially where were 2 childrewern e (1.8%). 2 childre n (1.8%). of whom woerf ewho gunshom wter victime gunshos. Tht evictim means . hospitaThe meal stn a yhospita l stay and personnel are ill equipped to cater for these critically jor surgical and other disciplines. The Accident and Emer- was 7.1 ± 7.7w a(0s 7.- 261 ±) 7.da7y s(.0 - 26) days. ill patients. It is estimated that death from unintentional gency Unit of the hospital is a 15- bedded ward staffed Injuries Injuries trauma is on the increase in developing countries though by trauma doctors and nurses overseen by a trauma con- Blunt traumBluna accountet traumda foaccounter 99 (86.8%d for )9 9patients (86.8% whil) patientse whilFactoe rs Faffectingactors affecting mortality mo rtality not as significantly as that from infectious diseases like sultant, while a 6-bedded Intensive Care Unit caters for penetrating penetratinginjuries w erinjuriee 15s (13.6%)were 15. A(13.6%)utomobil. eA utomobilThee overall mortalitThe overaly wl amortalits 12 (11%y w)a patients 12 (11%s. A)t patientunivariates. A t univariate diarrhoea and malaria, while it is on the decrease in in- the critically ill. The hospital is strategically positioned in accidents causedaccident the s majoritcausedy th eo f majoritblunt ytraum of bluna (79.1%)t traum, a (79.1%)level, , the factorlevels, thathet factorwere sfoun thatd wtoer eb efoun associated to db e withassociate d with dustrialized countries (1). Previous reports on incidence a network of highways linking major cities in the South with 68.2%wit hin - 68.2volvin% g inpassenger- volvinsg whilpassengere 10.9s %whil were e1 0.9% wmortalitere y includemortalitd increasiny includeg d agincreasine, respiratorg agye , ratrespiratore, meany rate, mean of blunt versus penetrating injury from Nigeria have been West and other parts of Nigeria. pedestrians. pedestrianThe ve- hiculas. Ther vtypee- hiculas andr theityper s frequencieand theirs frequenciearterias l blooarteriad pressurl blooe dan dpressur ISS score ane.d T ablISSe scor1 she.ow Tsabl thee 1 shows the conflicting depending on the urbanisation of the region All patients with blunt or penetrating chest trauma are shown arine Figurshowen 1. i nOthe Figurr ecause 1. Othes of r bluncauset straum of bluna t traummultia variatemulti logistivariatc regressioe logistin c moderegressiol shno winmodeg thl esh indeowin-g the inde- as well as prevailing circumstances of peace or regional presenting to the Accident and Emergency Unit of the include crushinincludg bey crushinobjectsg by objects pendent predictorpendens to predictorf mortalits y o ifn mortalitthe patienty ins thwite hpatient chest s with chest armed violence which occur sporadically (2-3). OAUTH, Ile-Ife and having had appropriate chest radio- 5 (4.6%), fall5 s(4.6%) from ,height falls sfro 2(1.8%m height) ans d2(1.8% electrocution) and electrocution injur y in ourinjur centry ein. our centre. We have examined the spectrum of these civilian chest in- graphs, were prospectively entered into a database which 1(0.9%). 1(0.9%). For every onFeo ry eeavrer increasy one ey ea inr increasage, there ei n wagase ,a nther 8%e wina-s an 8% injuries during times of peace to determine the incidences was collected over a period of two years (May 2008 – Gunshot woundGunshos accountet woundds fo accounter 8% of dches for t 8injurie% of sches andt injurie s creaseand d risk creaseof mortalitd risk yo fafte mortalitr adjustiny afteg rfo adjustinr the effecg fot rof th e effect of of blunt and penetrating injuries and the outcomes of April 2010). All patients who did not require chest radio- was the commoneswas the tcommones cause (9/15t caus; 60%e )(9/15 of ;penetrating 60%) of penetratingdifference s idifferencen gender, styp ine gende of vehiclr, type, emea of vnehicl arteriae, meal bloodn arteria l blood our management strategies, evaluating the emergency graphs after careful physical examination were excluded chest injury.ches Othet injurr penetratiny. Otherg penetratininjuries wger injuriee froms stabswere from stabspressur e at pressur presentatione at presentation, time to presentation, time to presentation, respira- , respira- room initiation of care for these critically ill patients to from the analyses. (5/15; 33.3%(5/15) an;d 33.3%fall unt) oan ad sharfall punt objeco a tshar (1/15p objec; 6.7%).t (1/15 ; 6.7%).tory rate andtor ypuls ratee rataned apulst presentatione rate at presentation. The higher. Ththee higher the determine factors that may contribute to mortality and The demographics, mechanism of injury, time to presen- The medianTh time emedia to presentation time to npresentatio was 120 minuten was s1 2(inter0 minute- s (interISS -scor e, theIS greateS scorre , ththee risgreatek of rmortalit the risky o ifn mortalitthis cohory itn ofthi s cohort of ascertain whether our current setup is achieving results tation, vital signs on admission, injury sustained, Injury quartile rangquartile 40 e– 54rang0 eminutes) 40 – 54.0 Th minutes)e front sea. Tht epassen front -sea t passenpatient- s. Forpatient every suni. Fto rincreas every euni int thincrease ISS,e thine thodde sISS ratio, the odds ratio comparable with other trauma centers. Severity Score (ISS) as well as management instituted gers of cars (35.5%gers of car) ans d(35.5% passenger) ansd ipassengern the secons idn rthowe seconof d rowfo rof mortalit yfo wr amortalits 1.27 (95y w%a s C1.2I 1.7 0(959 –% 1.49) CI ,1. p0 9= –0.0 1.49)03. , p = 0.003. were evaluated. buses (35%)buse wers e(35% the mos) wter elikel they mosto suffet likelr chesy tot suffetraumar ches t trauma while the driwhilver eo fth ae cadrir vwera so fmor a cae rlikel wasy morto suffee likelr chesty to suffer chest

The AnnAls of AfricAn surgery • Volume 9 • July 201215 201216 Jul201216y 2012 • VJulolumy 201e 9 2• The• Volum Anne A9 l• s The of AnnAfricAlAsn of AfricAn surgery surgery The ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 79 The AnnAls of AfricAn surgery | www.sskenya.org

carnage of road traffic accidents by the Federal Road Safe- Discussion ty Corps, which enforces the use of seat belts, increasing Previous reports on chest trauma have documented a awareness of road safety among road users etc. Seat belt variable incidence of chest injuries from 10% in develop- usage is still very poor at 8.3% among commuters with ing countries like India (4) to about 25% - 50% of total only 36% of drivers who suffered chest injuries using trauma in developed countries of Europe (5). Although them at time of impact. Unfortunately, many vehicles do data of chest trauma are not readily available from devel- not have functioning seat belt devices especially the 14- oping countries, Adesunkanmi et al (6) reported 2.5% of 16 seat buses which are commonly used for mass human total trauma admissions among the pediatric age groups transportation in Nigeria. Although the use of seatbelts in our institution a decade ago, while our study recorded could ironically be implicated in certain lateral impacts only 6% of our total trauma admissions both suggesting by keeping the passenger fixed in his seat and increase a generally lower incidence than industrialized societies. the energy dissipated to the victim from the vehicular However, this may be due to under-reporting as occurs components (11), this is rare and was not demonstrated with many cases of trauma in developing countries. This in our patients. The contribution of poorly maintained may also be responsible for the low absolute numbers of roads and vehicles as well as failure to keep to traffic rules chest trauma seen during the study period. and lack of organized rescue mechanisms play an enor- It is estimated in some studies that thoracic trauma ac- mous role in the high frequency and morbidity of road counts for about one quarter of deaths from trauma traffic accidents. A lot more still needs to be done by the though two thirds of these deaths unfortunately occur in government to further reduce the morbidity and mortal- a hospital facility (7). In our setting, this is difficult to ity figures. substantiate as post mortems on dead trauma victims are The first 60 minutes after injury has often been described not routinely performed for various religious and cultural by trauma experts as the ‘golden hour’ and is the most reasons. However, it is believed that death from uninten- effective for saving lives (12). Improved quality of patient tional trauma is on the increase in developing countries care has also been linked to ability to considerably reduce though still behind infectious diseases like diarrhoea this time to intervention which is often now measured and malaria, while it is on the decrease in industrialized in minutes. The median time to intervention by trained countries (1). personnel of 2.5 hours in our study is rather long, and Our study showed that active males (78%) still remain may explain why no major vascular and cardiac injuries the population at greatest risk despite the supposed in- presented to our facility during this period as these may creasing role of women outside the home to support the have expired at the scene of accident or shortly on arrival domestic income. A slightly older but comparable mean at hospital. Even though time to presentation was not age of 40±16 years in our study might be attributed to found to be significant for in-hospital mortality (p>0.05) older people seeking better economic prospects. How- (Table 1), this could be as a result of relatively small sam- ever, this is still comparable to other studies from Nigeria ple size. There is unfortunately no organized pre-hospital and elsewhere (8,9,10). emergency care presently to extricate and transport these Small to medium scale traders on business trips to individuals to health facilities expeditiously and as such, neighboring cities, formed the largest occupation group this vital role is often played by volunteers and passersby (23.9%) amongst the victims, reflecting the large business who are largely ignorant of many life saving procedures. community of South Western Nigeria. Another emerging Many of the victims suffer more injury from untrained population at risk are students of higher educational in- hands who are really doing their ‘best’ to help! The siting stitutions (13.8%) who are exposed as they ply the high- of mobile clinics at strategic intervals on our highways ways during university holidays or unfortunate closures armed with trained ATLS personnel would go a long way of their university campuses for one reason or the other. to providing the much needed emergency care before on- Our study showed that motor vehicle crashes (cars and ward transfer to more sophisticated care. buses) were responsible for the majority of injuries While most of our patients sustained blunt injuries to (78%), which though comparable to other countries, is the chest, only 13.6% sustained penetrating chest inju- rather high in spite of efforts to reduce the incidence and ries out of which 8% were due to gunshot injuries during

The AnnAls of AfricAn surgery • Volume 9 • July 201217 80 The ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 Original OriginalOriginal article Articlearticle The ANNALS of AFRICAN SURGERY | www.sskenya.org

The PatteTher nP atteandr nOutcom and Outcome of Chese oft ChesInjuriet sInjurie in Souts inh SoutWesth NiWgeseriat Ni geria OgunrombOgunrombi A.B., Onakpoyi A.B., Onakpoya U.U., aEkrikp U.U.o, EkrikpU., Adesunkanmo U., Adesunkanmi A.K., Adejari A.K.e, AdejarI.E. e I.E.

UnivariateUnivariat analysise analysis MultivariatMultivariate analysise analysis odds ratio odd (95s% rati CIo ) (95p-value% CI ) p-value odds ratio odd (95s% rati CIo ) (95p-value% CI ) p-value Female seFemalx e sex 0.83 (0.210.8 – 3.313 (0.2) 0.791 – 3.31 ) 0.79 1.79 (0.121.7 – 297 (0.1.76)2 0.68 – 27 .76) 0.68 Age (years) A ge (years) 1.04 (1.011.0 – 1.084 (1.0) 0.031 – 1.08 ) 0.03 1.08 (1.011.0 – 1.178 (1.0) 0.031 – 1.17 ) 0.03 Vehicula r tVype/ehiculaPedestrianr type/P edestrian Bus Bus 1 1 1 1 Car Car 0.99 (0.210.9 – 4.799 (0.2) 0.991 – 4.79 ) 0.99 0.46 (0.040.4 – 5.316 (0.0) 0.534 – 5.31 ) 0.53 Mot orcycleMo torcycle 1.42 (0.231.4 – 8.712 (0.2) 0.703 – 8.71 ) 0.70 0.01 (0.000.04 –1 1.03(0.00) 0.054 – 1.03 ) 0.05 Pedestrian P edestrian 1.32 (0.271.3 – 6.482 (0.2) 0.737 – 6.48 ) 0.73 1.28 (0.051.2 – 30.948 (0.0)5 0.88 – 30.94 ) 0.88 Mean a rteriaMeal bloon artderia pressurel blood pressure 0.97 (0.940.9 – 0.997 (0.9) 0.044 – 0.99 ) 0.04 1.01 (0.971.0 – 1.061 (0.9) 0.537 – 1.06 ) 0.53 Type of chesTypt einjury of ches t injury Blunt Blunt 1 1 1 1 Penetrating Penetrating 0.57 (0.070.5 – 4.787 (0.0) 0.617 – 4.78 ) 0.61 0.13 (0.040.1 – 3.843 (0.0) 0.244 – 3.84 ) 0.24 ISS ISS 1.17 (1.081.1 – 1.267 (1.0) <0.0018 – 1.26 ) <0.001 1.27 (1.091.2 – 1.497 (1.0) 0.0039 – 1.49 ) 0.003 Pulse ra te P(peulsre min) rate (per min) 0.96 (0.890.9 – 1.036 (0.8) 0.249 – 1.03 ) 0.24 0.96 (0.860.9 – 1.086 (0.8) 0.526 – 1.08 ) 0.52 Respira torRy espirarate (ctycles/min)ory rate (cycles/min) 1.14 (1.021.1 – 1.294 (1.0) 0.032 – 1.29 ) 0.03 0.97 (0.790.9 – 1.197 (0.7) 0.789 – 1.19 ) 0.78 Time to presentatioTime to presentation (minutes)n (minutes) 0.99 (0.990.9 – 1.009 (0.9) 0.499 – 1.00 ) 0.49 0.99 (0.990.9 – 1.009 (0.9) 0.219 – 1.00 ) 0.21

Table 1: LogisticTable 1: r egLogisticression r modelsegression showing models f actoshowingrs associated factors associated with mortality with mortality

armed armerobberied robberies and attemptes and attempted assasinationd assasinations, a slighs,t a in sligh- t in- ther interthevr entiointernv entiothereaften thereafter. Flail rches. Flait lw chesas not tw frequentlyas not frequently crease ovcreaser 5.5e ov%e ri n5.5 a %previou in a previous studys frostudm yNigeri from aNigeri by Anay -b y Any- encountereencountered (4.6%d )(4.6% and mos) antd requiremost drequire onlyd analgesics only analgesics anwu eat nawl u(8 )e tov ale (8r t)w ovo edecader two sdecade ago whers ageo thewhery identifiede they identified and chesantd drainag chest drainage whene occurrinwhen occurring with g pleura with l pleura collecl - collec- gunshogunshot woundt ws oundas ans infrequenas an infrequent and oftet annd accidentaloften accidental tions, wittionh snon, wite h requirin none requiring mechanicag mechanical ventilation.l ventilation. cause ocausf penetratine of penetrating injurieg sinjurie. Versy. fe Vwer ystudie fews studie reports report We recordeWe recorded onlyd 1 7onl (15.5%y 17 (15.5%) patient) patients with sevidenc with evidence of e of penetratinpenetrating injuryg ainjurs beiny gas morbeineg commonmore common. Soreid. eSoreid et al e et al pulmonarpulmonary contusiony contusions on chess otn radiograpchest radiograph which whicis deh- is de- (13), fro(13)m ,Scandin from Scandinavia, recordeavia, recorded a thirdd a(33% third) (33%of all) in o-f all in- fined afines pulmonard as pulmonary infiltratey infiltrates folloswin follg otraumwing atraum in thea in the juries whiljuriees Alwhili ane d Al Gali ani d(2) Gal, froi (2)m , Nort fromh NortEast hNigeria, East Nigeria, presencpresence of heypoxaemia of hypoxaemia. Even . thougEven hthoug pulmonarh pulmonary con- y con- report penetratinreport penetrating injuryg occurrininjury occurring in 61.5g %in 6o1.5f case% so fdur case- s dur- tusion tusiomay n h avmea ya hvaverey asignifican very significant impact t impac on mortalityt on mortality ing communaing communal conflictl conflicts. Therse. appearThere sappear to bes a t ochanging be a changing (15), w(15)e cautio, wen cautio that n infiltrate that infiltrates in thse ichesn thte radiographchest radiograph trend wittrenh dsuc with hinjurie such sinjurie occurrins occurring moreg frequentlmore frequently fromy from could bcoule nond -bspecifie non-cspecifi or evce no rabsent even . absent It ma.y Ibt em difficultay be difficult banditsbandit. Stab sw. Staoundb ws oundfrom s bottle froms bottleand skni anveds kniarev einfres ar-e infre- to quantifto yquantif the degrey thee degreof pulmonare of pulmonary contusioy contusion on chestn on chest quentlyquentl seen y(4.5% seen )(4.5% and ther) aned w theras ae caswaes oaf casa fale ol ffro a mfal la from a radiographradiographs and simpossibl and impossible whene whexrayns arxreay nos tar ee vnoent even height heighunto ta untsharo p a farminsharp gfarmin implemeng implement causintg causin an openg an open availablaev.ailabl e. pneumothoraxpneumothorax. Sport.s Sportrelatesd relateinjuried sinjurie and s fall ansd fromfalls from Chest ultrasounChest ultrasound may hdav mea ya hsensitivitave a sensitivity of 94y% o ifn 94 detect% in- detect- heights heightwere srarel werye encountererarely encountered in oudr iserien ousr aseries opposeds as opposed ing contusioning contusions (4), bus t(4) w,e buhavt ew ene hvavere needeneverd neede to resord tto toresor t to to someto studiesomes studiein desv elopein dedv elopecountried countries wherse theswhere e wthesere e were this or thichess to rC chesT in tth CeT acut in the emanagement. acute management. more frequentlmore frequently seen y( 1 see0). n (10). There iThers a ehig ish aincidenc high incidence of traumatie of traumatic hemothorac hemothorax or x or WorldwidWorldwide, rib efracture, rib fractures are ths e ar mose thte commo most common patholn -pathol - pneumothorapneumothorax or a xcombinatio or a combination of bothn o, f requirinboth, requiring in- g in- ogy associateogy associated with dblun witth chesblunt ttraum chesta traum (8,10,14a (8,) 1an0,14d this) an d this tercostatercostal drainagl drainage. We erel. yW oen relclinicay on l clinicaexaminationl examination, tho- , tho- is consistenis consistent with tou witr resulth ours result(46.3%)s (46.3%). All patient. All patients with s with racocentesiracocentesis and sches antd radiograph chest radiographs, whicsh, whicare relatih arev elyrelati vely isolatedisolate singlde risinglb fracturee rib fractures were smanage were managed as outpatientsd as outpatients easy to eaobtaisy ton obtaiin ounr icentrn ouer, centrto determine, to determine need efo neer chestd fo r chest requirinrequiring no morg neo thamorn e analgesic than analgesics with s instruction with instructions to s to tube drainagtube drainage. We eh. av We e foun havde founthat d thoracocentesi that thoracocentesis is a s is a return returafter n24 afte-48r hour24-4s8 fohourr as repea for at chesrepeat t radiograpchest radiograph to h to fairly reliablfairly ereliabl predictoe predictor of pleurar of l pleuracollectiol collection especiallyn especially reassessreasses the pleuras the l pleura spacel. Hspacowe.v eHr,o wnoneveer , require none drequire fur- d fur- followinfollg otraumwing atraum and ashoul and d shoul be utilized be d utilize wherde whercheste chest

201218 201218 July 201 Jul2 y• 201Volum2 •e V9olum • Thee Ann9 • TheA lAnns of AfricAls of AAfricn An surgesruyr gery The ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 81 The AnnAls of AfricAn surgery | www.sskenya.org

ISS score Associated injury Outcome

25 Head Injury Died 45 Electrical burns Died 34 Head Injury Died

27 Paraplegia Died 43 Head Injury/rupt spleen Died

38 Mangled limb Died 27 Paraplegia Alive 27 Head Injury Alive

27 Bilateral hemo Died 27 Femur # Alive

27 Avulsion foot Alive

29 Splenic rupture Alive Figure 1: Frequency of Involvement by Vehicular Type 27 Tibia + Fibula # Died

27 Femur # Alive 27 Head Injury Alive 34 Head Injury Died

34 Splenic rupture Alive 25 Pelvic # Alive

27 Bilateral hemo Alive 27 Paraplegia Alive 27 Femur # Alive

25 Pelvic # Alive 43 Avulsion limb Alive

Table 2: Analysis of Severe ISS (>25) Figure 2: Injury Severity Score

radiographs may not be easily available. It is important while head injury occurred in 29.6%. Associated abdom- therefore that frontline doctors be proficient in recogniz- inal injuries seen in only 10% were usually severe, and ing traumatic pleural collections as well as inserting chest often required exploratory laparatomy. There was the rare tubes. case of evisceration in the patient who suffered 95% elec- Thoracotomy is indicated especially when chest tube trical burns and succumbed shortly after. The presence of output exceeds 250 mls per hour for up to 3 hours, or associated injuries worsened the ISS classification which an initial chest tube output of >1000mls (16). Only 5 was significantly associated with mortality (P<0.001) of our patients required this and all but one were due (Table 1). Central nervous system injuries accounted for to penetrating injury. The findings at surgery included more than half (56%) the mortalities of severe (>25) ISS bleeding from lung parenchymal injuries requiring only scores. (Table 2). suture ligation in three patients, diaphragmatic tear with Mortality significantly increases with age (10) and we hepatic injury in one patient and intercostal artery injury have found that the risk of dying increases by 8% for ev- in another. ery year increase in age (p=0.03). This might be a result Injury Severity Scoring has been devised to predict out- of the negative contribution of comorbid factors with income of trauma cases and has correlated with morbid- creasing age. Tachypnea on admission also correlated sig- ity, mortality and hospitalization time in many studies nificantly with poor outcome at univariate level (p=0.04), (9,17). We observed that limb fractures in 35.8% of our but this was insignificant at multivariate analysis patients were the most common concomitant injury (p=0.78) possibly because of multifactorial causes such

The AnnAls of AfricAn surgery • Volume 9 • July 201219 82 The ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 Original Article The ANNALS of AFRICAN SURGERY | www.sskenya.org Original Original articles articles

The PatteThren P anatted rOutcomn and Outcome of Chese otf InjurieChests Injurie in Souts ihn WSoutest hNi Wgeseriat Ni geria OgunrombOgunrombi A.B., Onakpoyi A.B., aOnakpoy U.U., Ekrikpa U.U.o , U.Ekrikp, Adesunkanmo U., Adesunkanmi A.K., Adejari A.K.e, I.E.Adejar e I.E.

as pain oasr paianxietn oyr anxietand noy t annecessarild not necessarily chest ytraum chesat traumper se.a per se. 6. Adesunkanm6. Adesunkanmi ARK, Oginni ARKi , LMOginn, Oiy elamLM,i OOyelamA, eti alO. AR, oadet al. Road HoweverH, owsimpleveer, strategiesimple strategies of vitasl signof vitas monitoringl signs monitoring, even , even traffic accidenttraffic s accident to Africas tno childrenAfrican: children assessmen: assessment of severityt of severity in poor i nresourc poor eresourc environmente environments with onls wity hth eonl mosy tht eba mos- t ba- using theusin Injurg yth eSe Injurverity ScorSeverite. yInjur Scory, e .In Injurt .J.y Car, Inet Injured..J. Care Injured. sic of equipmentsic of equipment, will promptl, will promptly recognizy recognize patiente spatient with s with 2000;31:2252000;-22831:225 -228 severe ISseSv anered IS goS ana lond ggo waa lony ing reducinway in greducin morbiditg morbidity and y and 7. Evan7s. BJ ,E Hornicvans BJk, HornicP. Blunkt injurieP. Bluns t tinjurieo the schest to .th Surgere chesty. (OxSurger- y (Ox- mortalitmortality. y. ford) 200ford5; 2)3 2(0101):45; 2039 -(4111):41. 09-411. Our hospitaOur lhospita mortalitl mortality of 11%y o ifs 1slightl1% isy slightlhigheyr highethan r than 8. Anya8n. w u A nyCHan, w Suw aruCHp, ASSwaru. Chesp ASt traum. Chesat itraumn a dea vielopingn a dev eloping what Anywhaantw Au nyeta anlw (8u ) etfoun al (8d ) (9.7%found) (9.7%about )t wabouo decadest two decades country. Ancountrn Ry Col. Anl nSur Rg Col Engll Sur. 19g 8Engl1;63:. 191028-1;63:104 102-104 ago fromag oth efro Easterm then Easterpart onf Nigeriapart of , Nigeriaand ver, yan comparad very compara- - 9. Hildebran9. Hildebrand F, Giannoudid F, Giannoudis PV, Grienss PVve, nGriens M, evte nal . MManage, et al. - Manage- ble to Abltrie etto a Al frotri met aIndia.(12.1%l from India.(12.1%) (4). Ho) w(4)ev.e rH, othoughwever, though ment ofmen polytraumatizet of polytraumatized patientds patientwith sassociate with dassociate bluntd blunt our mortalitour mortality figuresy mfigureay bse mdeceptiay bev deceptiely lowveelr ytha lonw ewhatr tha n what chest traumaches:t traumaa compariso: a comparison of two nEuropea of two nEuropea countrien scountrie. In- s. In- obtains obtainfrom ssom froem reportsomes reportfrom s thfroe mde vthelopee dedv elopeworldd world jury. 2005;36:293jury. 2005;36:293-302 -302 (9,18), w(9,18)e realiz, wee tharealizt theie thar cohort theitr ocohorf patientt of spatient may bes mdifay- be dif- 10. Lima1n0 . S LimaT, Kuzucn SuT , AK,uzuc Tastepu Ae , AITastep, et ale .AI Ches, et t al injur. Chesy tdu injure toy due to ferent aferens we t d oas nowet dreceio novet patientreceive spatient with ses vwitereh cardiac,severe cardiac, blunt traumablunt. Eutraumar J Cardiothora. Eur J Cardiothorac Surg. 20c0 Surg3; 23:374. 2003-; 378.23:374 -378. airway anairdwa vyascula and rv asculainjuriers injuriepossibls ypossibl due tyo suboptimaldue to suboptimal 11. Nirul1a1 . RNirul, Pintaa r R ,F APinta. Identificatior FA. Identification of vehicln oef componentsvehicle components extricatioextrication and ntranspor and transport to hospitat to lhospita resultinl gresultin in deathg in death associatedassociate with d se vwitereh thoraci severec thoraci injuryc i ninjur motoy irn vmotoehicler vehicle prior to prioarrivinr tog arrivinin hospital.g in hospital. crashes: Acrashes CIRE:N A an CIREd NASN anS anald NASysisS. analAcciydsi Anas. Alcci Pred vAna 2008;l Pre v 2008;

40(1):13740(1):137-141. -141. ConclusionConclusion 12. Bigdel12i. MBigdel, Khorasanii M, Khorasani-Zavareh- ZDav, areMohammadh D, Mohammadi R. Prehosi R-. Prehos- MajorityMajorit of they patientof the spatient requiresd require only dminima only minimal intervenl interven- pital carepita timl ecar intere timvales interamonvalgs victimamongs ovictimf roads otraffif roac din traffi- c in- tion wittioh neithe witr hches eithet rdrainag chest edrainag or analgesice or analgesics, achievins, achieving a g a juries in jurieIrans. Ain crosIrans. sectionaA crossl sectiona study. lBM studC yPubli. BMc C Health. Public Health. low mortalitlow mortality. Howeyv.e rH, o somweve r , patient some spatient may hsa vme ayassoci have- associ- 2010;10:406201 0;10:406 ated extrathoraciated extrathoracic injuriecs injurie requirins grequirin multidisciplinarg multidisciplinary at- y at- 13. Soreid13e. KSoreid, Soilane Kd , HSoilan, Lossiud Hs , HMLossiu, ets alHM. R,esuscitati et al. Rvesuscitatie emer-v e emer- tention.tention Promp. t Prompextricatiot extrication for chesn fot rtraum chesta traumvictimas victimat s at gency thoracotogency thoracotomy in a mScandiny in a aScandinvian traumaviaan hospitaltrauma -hospital Is it - Is it the site thase w sitelel aass awt eltrauml as aat traumcentresa icentres still slackin is stilgl lackinand thisg an d this justified? justifiedInjury, ?Int.J Injur. Cary, eInt.J Injured. Car.e 2Injured007; 38:34. 200-742.; 38:34 -42. must bemus imprt boev ed.impr oved. 14. Kalyanarama14. Kalyanaraman R, DeMelln R,o DeMell WF, Roa vishankaWF, Rarvishanka M. Manager M. - Manage-

ment of menchest injurieof chess t –injurie a 5 ysea –r retrospectia 5 year retrospective surveyv.e Injur survye.y . Injury. ReferencesReferences 1998;29:4431998;29:443-446 -446 1. Otien1.o T Otien, Woodfielo T, dW oodfielJC, Bird PJC, e,t Bir al.d T Praum, et ala . iTnraum rurala Kine nruraya. l Kenya. 15. Kwo15n .A Kw, Sorrellon As, SorrellDL, Ksurkchubasch DL, Kurkchubasche AG, eet alA.G ,Isolated et al. Isolated Injury, Int.JInjur. Cary, eInt.J Injured. Car.e 2Injured004; 35:1228. 2004; -35:12281233. -1233. computecomputed tomograpd tomography diagnosihy sdiagnosi of pulmonars of pulmonary contusiony contusion 2. Ali N2,. Gal Ali iBM N, .Gal Patteri BMn .an Patterd managemenn and management of chestt injurof chesy int injury in does not doe correlats note correlatwith increasee with d increase mortalitd ymortalit. J Pediaty.r J Surg.Pediat r Surg. MaiduguriMaiduguri, Nigeria., AnNigerian Afr. MedAnn. Af2004r Med; 13(4):1. 2004;8 113(4):1-184. 81-184. 2006;41:782006;-824 1:78-82 3. Misaun3. o Misaun MA, Sulo eMA AZ, ,Sul Nwe andialAZ, Now HCandial, eto alHC. ,Se etver ale ches. Setv ere chest 16. Onat16 S. , OnaUlkut RS, UlkAvcui AR, ,e At valc.i AUrgen, et alt . thoracotoUrgent thoracotomy for penmy- for pen- trauma intraum Jos, Nigeriaa in Jos:, PNigeriaattern :and Patter outcomn ande outcom of managemente of management. . etrating chesetratint taumag ches: tAnal taumaysi:s Analof 15y8si spatient of 158s opatientf a singls oef cena singl- e cen- NJOT 200NJ7.O l6T; 2(2)00:7 .64 l6-;66 (2) : 64-66 ter. Injuryte, rInt.J. Injur. Cary, eInt.J Injured. Car.e 2Injured010; 4.1:876 2010-;880. 41:876 -880. 4. Atri 4 M. , ASingtri hM ,G Sing, Kohlh iG ,A .K ohlChesi tA .traum Chesat itraumn Jamma iun Jammre- u re- 17. Chaw17da. ChMNaw, dHildebrana MN, Hildebrand F, Paped HCF, P, apete alHC. Predictin, et al. gPredictin out- g out- gion: an gion institutiona: an institutional study. Inl dstud J yThora. Indc JCardi Thoraovcas Cardic Surg.ovas c Surg. come aftecomr multiple aftere multipltrauma:whice trauma:which scoringh sy scorinstem?g Injursystemy, ?Int Injur y, Int 2006;22:219006;22:-222 219-222 J. Care InjuredJ. Car.e 2Injured004; 35(4):347. 2004; 35(4):347-358. -358. 5. Hunt5 . P A Hun, Gret avPAes, GreI, Oavweens sI , WOAw.en Emergencs WA. Emergency thoracotoy thoracotomy my 18. Clark18 GC. Clar, Schectek GCr, SchecteWP, Trunker WPy, TDDrunke. Variabley DD. sV affectinariablesg affectinout- g out- in thoraciinc thoracitraumac –traum a reviea –w .a Injurreviey,w .Int Injur. J.y ,Car Inte . Injured. J. Care Injured. come in comblunet ichesn blunt traumat ches:t flaitraumal ches: tflai vsl. chespulmonart vs. pulmonary contu- y contu- 2006;37:12006;37:1-19 -19 sion. J Traumasion. .J T1988rauma; 28:298. 1988-; 328:29804. -304.

201220 201220 July 201 2Jul • y V201olum2 e• 9 V olum• The eAnn 9 • TheAl Anns of AfricAls ofA Africn AnThe ANNALS of AFRICAN SURGERY. July 2012 Volume 9 Issue 2 83 surgesruy rgery