Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest Abstract OBJECTIVES This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. METHODS We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities. RESULTS Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients. CONCLUSIONS CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized. Lung, Pleura, Pneumothorax, Thoracotomy, Trauma, Penetrating, Imaging INTRODUCTION The added diagnostic value of computed tomography (CT) over chest X-ray (CXR) in patients with blunt trauma to the chest has been extensively verified [1, 2]. Chest CT has been demonstrated to reveal underestimated or overlooked injuries [3], to positively influence selection of treatment strategies [4] and to improve outcomes in patients [5, 6]. In comparison, the value of chest CT in the management of patients with penetrating war injuries to the chest has not been widely studied, and only limited data are available on injured patients who are expected to benefit from undergoing CT of the chest [6, 7]. More specifically, routine use of chest CT deserves reconsideration at times of war due to the frequent overload of available medical resources and the potential for managing findings of uncertain clinical importance, with unnecessarily extended in-hospital stays. This study was performed to define and compare the contributions of CXRs and chest CTs towards detecting intrathoracic damage in patients with penetrating war injuries and to determine whether identification of certain additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. PATIENTS AND METHODS Since the outbreak of the Syrian crisis in early 2011, the Mouassat University Hospital has been serving civilian casualties evacuated directly to its premises, and its surgical services have dealt with a growing number of injuries of various aetiologies. Basic guidelines were set by the surgical teams to direct patients’ management (Fig. 1). All patients with penetrating war injury to the chest received an immediate screening CXR, whereas chest CT was performed at the discretion of the thoracic surgery team (Table 1). Parasternal wounds were routinely screened for haemopericardium using transthoracic echocardiography. Follow-up CXRs were performed after every therapeutic intervention and were repeated on a daily basis afterwards. Patients were selected for primary conservative management if they were haemodynamically stable with no significant pneumothorax or haemothorax. Patients who were nominated for surgical treatment received closed chest drainage as a first-line intervention and were subjected to open thoracotomy if the initial drainage volume exceeded 1500 ml or ongoing blood loss was more than 250 ml/h for 3 consecutive hours. Immediate thoracotomies were performed in patients who were in a state of shock (e.g. tamponade and visible haemorrhage), where major cardiac or vascular injuries were suspected or where abnormal chest CT findings required operative intervention. Table 1: Common indications for performing additional chest CTs after screening CXRs 1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  CT: computed tomography; CXR: chest X-ray. Table 1: Common indications for performing additional chest CTs after screening CXRs 1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  CT: computed tomography; CXR: chest X-ray. Figure 1: View largeDownload slide Basic management algorithms for (A) stable and (B) unstable patients with penetrating war injuries to the chest. CT: computed tomography; CXR: chest X-ray. Figure 1: View largeDownload slide Basic management algorithms for (A) stable and (B) unstable patients with penetrating war injuries to the chest. CT: computed tomography; CXR: chest X-ray. This retrospective study and data collection were approved by the hospital’s research and ethics committee. Data were collected from hospital records of all patients who were admitted to the hospital with the diagnosis of penetrating war injuries to the chest over a 7-year period (from 1 January 2011 to 31 December 2017). For the purpose of this study, a penetrating war injury to the chest was defined as any penetrating injury between the clavicles superiorly and the 12th rib inferiorly that was acquired as a result of military activities. Records of patients who died before admission were not included in this review. Collected clinical data included patient demographics, mechanism of injury (shrapnels, firearm bullets or stab wounds), associated injuries, evacuation times from the primary sites of injury, physiological parameters on admission, results of CXRs and chest CTs (pleural effusion, haemothorax, pneumothorax, pneumomediastinum, pulmonary contusion, costal/sternal/scapular/vertebral fractures and injuries to the aorta, diaphragm, tracheobronchial tree or oesophagus), therapeutic interventions (closed chest drainage, open thoracotomy, laparotomy, etc.), ventilation requirements, length of hospital stays, complications and mortalities. An impact on patient treatment strategy was defined as any change in management plan (including admission for observation, additional imaging studies, referral to other specialties or immediate therapeutic interventions) that was based on the identification of certain additional injuries using chest CT. Statistical calculations were made using the GraphPad Prism® V0.5 software (GraphPad Software Inc., La Jolla, CA, USA). Values are expressed as mean ± standard deviation. RESULTS From January 2011 to December 2017, 449 patients (374 men, mean age 29.3 ± 14.8 years) with penetrating war injuries to the chest were admitted to the Mouassat University Hospital and were managed by the thoracic surgery service. The main mechanisms of penetrating war injuries to the chest in our experience were shrapnel injuries due to explosions (36%), firearm bullets (32%) and stab wounds (32%) (Table 2). Table 2: Distribution of various chest injuries according to mechanisms of injury   Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)      Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)    CXR: chest X-ray. Table 2: Distribution of various chest injuries according to mechanisms of injury   Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)      Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)    CXR: chest X-ray. Emergent thoracotomies without initial screening CXRs were performed in 30 (6.7% of all patients) patients who were in grave clinical states of shock (due to cardiac tamponade in 11 patients and acute visible haemorrhage in 19 patients). Immediate screening CXRs were obtained in all other patients (n = 419), of which 8.6% were read as showing no signs of intrathoracic damage, whereas 91.4% showed positive signs of injury (Table 3). Table 3: Major findings on immediate screening CXRs in 419 patients with penetrating war injuries to the chest   Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)    Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)  CXR: chest X-ray. Table 3: Major findings on immediate screening CXRs in 419 patients with penetrating war injuries to the chest   Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)    Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)  CXR: chest X-ray. After initial screening CXRs, 207 patients (49.4% of imaged patients) underwent chest CTs, and 98.1% of those (n = 203) had had positive signs of injury on initial screening CXRs. Chest CTs confirmed CXR-positive findings in all cases, whereas it revealed 23 previously unidentified injuries in 11.1% of patients (Table 4). Table 4: Additional chest CT findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12      Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12    CT: computed tomography. Table 4: Additional chest CT findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12      Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12    CT: computed tomography. Based on the positive findings on initial screening CXRs (n = 383), decision was made to continue with conservative medical management in 36.1% of patients (n = 138), whereas closed chest drainage was considered in 37.6% of patients (n = 144), and open thoracotomy was performed in 26.3% of patients (n = 101). The additional findings on chest CT led to further therapeutic interventions (which was closed chest drainage) in 12 patients with newly identified haemothorax or pneumothorax. On the other hand, chest CT findings had no impact on patient treatment strategy in 94.4% of scanned patients (Table 4). Follow-up CXRs were performed in all patients on a daily basis until discharge, and new positive findings were noted in 22 patients (Table 5). Based on these findings, additional closed chest drainage was performed in 3 patients, and delayed open thoracotomies were performed to remove shrapnels located close to the aorta or lung hilum in 3 cases and to evacuate blood clots that trapped the lungs in 4 other patients. Table 5: Additional delayed CXR findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7    Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7  CXR: chest X-ray. Table 5: Additional delayed CXR findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7    Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7  CXR: chest X-ray. Of 449 patients with penetrating war injuries to the chest, 32.3% of patients (n = 144) were managed conservatively, closed chest drainage was performed in 42.5% of patients (n = 191), whereas open thoracotomies were performed in 25.2% of patients (n = 114) (Table 6). Associated extrathoracic injuries were present in 24.9% of patients [including splanchnic (n = 88), limb (n = 48), central nervous (n = 20) and vertebral injuries (n = 13)] and were managed according to standard protocols. The median hospital stay was 7.53 days (lower quartile = 4.89, upper quartile = 11.87), admission to the high-dependency unit was required in 15.4% of patients and artificial ventilation was indicated in 6.7% of patients for a median of 5.9 days (lower quartile = 4.11, upper quartile = 10.23). The overall in-hospital mortality rate was 8.4% (n = 38). Table 6: Distribution of methods of treatment according to types of intrathoracic injuries   Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)      Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)    Table 6: Distribution of methods of treatment according to types of intrathoracic injuries   Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)      Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)    COMMENT Despite the high diagnostic accuracy of CXRs in detecting major intrathoracic injuries [8], some investigators have highlighted that potentially life-threatening intrathoracic injuries may not be observed using CXRs because blood and air accumulation may be limited or delayed and an intact mediastinal or parietal pleura can stop blood from reaching the pleural cavities where it will be more discernable [9]. Moreover, studies have shown enhanced sensitivity of chest CTs over CXRs in patients presenting with blunt trauma to the chest and that chest CTs can reveal underestimated or overlooked injuries [10–12], with a positive influence on clinical management in many patients [11, 13], and an improvement in their outcomes [5, 6]. Medical practice recommendations at times of war frequently differ from everyday practice guidelines as several distinctive considerations must be taken into account at times of military conflicts. Pertinent to the present discussion, it would be impracticable to perform chest CTs in all patients with penetrating war injuries to the chest since hospital facilities would frequently be overburdened with casualties, in addition to the potential for misuse of the de facto limited medical resources. Further imaging, extended in-hospital stays, unnecessary invasive interventions such as closed chest drainage and unwarranted admissions to high-dependency units can all be consequences of managing findings of uncertain clinical importance. Hence, it would be very helpful to determine whether identification of additional injuries by chest CT will have a positive impact on the choice of therapeutic interventions and clinical outcomes in patients with penetrating war injuries to the chest. This review shows that initial screening CXRs in patients with penetrating war injuries to the chest are capable of revealing the majority of important intrathoracic injuries and that absence of positive signs of injury on initial screening CXRs excludes the presence of any damage in most patients. Although chest CT identified additional injuries (mainly haemothorax or pneumothorax and lung contusions) in approximately 11% of our patients, it is unlikely that these injuries would have been overlooked if chest CT was not done as they would likely have been detected on follow-up CXRs anyway [14, 15]. Moreover, the clinical significance of CT findings was very limited because they had no impact on patient treatment strategy in 94.4% of scanned patients, and there is evidence for the conservative management of small haemothorax or pneumothorax not apparent on initial screening CXRs [16, 17]. This understanding is reinforced by recent studies which indicated that chest CTs after abnormal CXRs rarely detect overlooked clinically significant injuries [10, 18, 19] and that chest CT findings are associated with only limited clinical consequences [2, 10]. On the basis of our experience, we believe that chest CTs can be omitted in most patients with penetrating war injuries to the chest, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized. Identifying injured patients who are expected to benefit from additional imaging with CT of the chest is important and requires larger reviews. Possible indications for performing chest CT may include defining projectile paths to help in planning surgical interventions and identification of damage caused by transmediastinal projectiles that may prove lethal if left untreated [7, 20–22]. Limitations This study does have several limitations. Data were collected retrospectively, and only half of all patients underwent chest CTs as discretion was left to the individual physician, which may have resulted in a selection bias. 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Ann Thorac Surg  2007; 83: 377– 82. Google Scholar CrossRef Search ADS PubMed  22 Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury  2007; 38: 48– 52. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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1569-9285
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10.1093/icvts/ivy152
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Abstract

Abstract OBJECTIVES This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. METHODS We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities. RESULTS Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients. CONCLUSIONS CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized. Lung, Pleura, Pneumothorax, Thoracotomy, Trauma, Penetrating, Imaging INTRODUCTION The added diagnostic value of computed tomography (CT) over chest X-ray (CXR) in patients with blunt trauma to the chest has been extensively verified [1, 2]. Chest CT has been demonstrated to reveal underestimated or overlooked injuries [3], to positively influence selection of treatment strategies [4] and to improve outcomes in patients [5, 6]. In comparison, the value of chest CT in the management of patients with penetrating war injuries to the chest has not been widely studied, and only limited data are available on injured patients who are expected to benefit from undergoing CT of the chest [6, 7]. More specifically, routine use of chest CT deserves reconsideration at times of war due to the frequent overload of available medical resources and the potential for managing findings of uncertain clinical importance, with unnecessarily extended in-hospital stays. This study was performed to define and compare the contributions of CXRs and chest CTs towards detecting intrathoracic damage in patients with penetrating war injuries and to determine whether identification of certain additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes. PATIENTS AND METHODS Since the outbreak of the Syrian crisis in early 2011, the Mouassat University Hospital has been serving civilian casualties evacuated directly to its premises, and its surgical services have dealt with a growing number of injuries of various aetiologies. Basic guidelines were set by the surgical teams to direct patients’ management (Fig. 1). All patients with penetrating war injury to the chest received an immediate screening CXR, whereas chest CT was performed at the discretion of the thoracic surgery team (Table 1). Parasternal wounds were routinely screened for haemopericardium using transthoracic echocardiography. Follow-up CXRs were performed after every therapeutic intervention and were repeated on a daily basis afterwards. Patients were selected for primary conservative management if they were haemodynamically stable with no significant pneumothorax or haemothorax. Patients who were nominated for surgical treatment received closed chest drainage as a first-line intervention and were subjected to open thoracotomy if the initial drainage volume exceeded 1500 ml or ongoing blood loss was more than 250 ml/h for 3 consecutive hours. Immediate thoracotomies were performed in patients who were in a state of shock (e.g. tamponade and visible haemorrhage), where major cardiac or vascular injuries were suspected or where abnormal chest CT findings required operative intervention. Table 1: Common indications for performing additional chest CTs after screening CXRs 1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  CT: computed tomography; CXR: chest X-ray. Table 1: Common indications for performing additional chest CTs after screening CXRs 1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  1. Clinical or CXR findings suggestive of great vessel injury.  2. Suspected diaphragmatic rupture or tracheobronchial injury.  3. Fractures of the thoracic spine or sternum, or sternoclavicular dislocation.  4. Centrally located shrapnels.  CT: computed tomography; CXR: chest X-ray. Figure 1: View largeDownload slide Basic management algorithms for (A) stable and (B) unstable patients with penetrating war injuries to the chest. CT: computed tomography; CXR: chest X-ray. Figure 1: View largeDownload slide Basic management algorithms for (A) stable and (B) unstable patients with penetrating war injuries to the chest. CT: computed tomography; CXR: chest X-ray. This retrospective study and data collection were approved by the hospital’s research and ethics committee. Data were collected from hospital records of all patients who were admitted to the hospital with the diagnosis of penetrating war injuries to the chest over a 7-year period (from 1 January 2011 to 31 December 2017). For the purpose of this study, a penetrating war injury to the chest was defined as any penetrating injury between the clavicles superiorly and the 12th rib inferiorly that was acquired as a result of military activities. Records of patients who died before admission were not included in this review. Collected clinical data included patient demographics, mechanism of injury (shrapnels, firearm bullets or stab wounds), associated injuries, evacuation times from the primary sites of injury, physiological parameters on admission, results of CXRs and chest CTs (pleural effusion, haemothorax, pneumothorax, pneumomediastinum, pulmonary contusion, costal/sternal/scapular/vertebral fractures and injuries to the aorta, diaphragm, tracheobronchial tree or oesophagus), therapeutic interventions (closed chest drainage, open thoracotomy, laparotomy, etc.), ventilation requirements, length of hospital stays, complications and mortalities. An impact on patient treatment strategy was defined as any change in management plan (including admission for observation, additional imaging studies, referral to other specialties or immediate therapeutic interventions) that was based on the identification of certain additional injuries using chest CT. Statistical calculations were made using the GraphPad Prism® V0.5 software (GraphPad Software Inc., La Jolla, CA, USA). Values are expressed as mean ± standard deviation. RESULTS From January 2011 to December 2017, 449 patients (374 men, mean age 29.3 ± 14.8 years) with penetrating war injuries to the chest were admitted to the Mouassat University Hospital and were managed by the thoracic surgery service. The main mechanisms of penetrating war injuries to the chest in our experience were shrapnel injuries due to explosions (36%), firearm bullets (32%) and stab wounds (32%) (Table 2). Table 2: Distribution of various chest injuries according to mechanisms of injury   Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)      Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)    CXR: chest X-ray. Table 2: Distribution of various chest injuries according to mechanisms of injury   Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)      Number of incidents  Percentage of patients  Mechanism of injury, % (n)   Shrapnels  Bullets  Stabs  Overall occurrence  449  100  36.1 (162)  32.1 (144)  31.8 (143)  Haemothorax  270  60.1  47.4 (128)  36.7 (99)  15.9 (43)  Pneumothorax  246  54.8  24 (59)  10.1 (25)  65.9 (162)  Pulmonary contusion  88  19.6  59.1 (52)  40.9 (36)    Diaphragmatic rupture  46  10.2  52.2 (24)  23.9 (11)  23.9 (11)  Rib fracture  19  4.2  42.1 (8)  52.6 (10)  5.3 (1)  Cardiac injury  12  2.7  41.6 (5)  16.6 (2)  41.6 (5)  Pneumomediastinum  3  0.7  66.6 (2)    33.3 (1)  Great vessels injury  2  0.4    100 (2)    Oesophageal injury  1  0.2    100 (1)    CXR: chest X-ray. Emergent thoracotomies without initial screening CXRs were performed in 30 (6.7% of all patients) patients who were in grave clinical states of shock (due to cardiac tamponade in 11 patients and acute visible haemorrhage in 19 patients). Immediate screening CXRs were obtained in all other patients (n = 419), of which 8.6% were read as showing no signs of intrathoracic damage, whereas 91.4% showed positive signs of injury (Table 3). Table 3: Major findings on immediate screening CXRs in 419 patients with penetrating war injuries to the chest   Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)    Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)  CXR: chest X-ray. Table 3: Major findings on immediate screening CXRs in 419 patients with penetrating war injuries to the chest   Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)    Number (%)  Normal (no signs of intrathoracic injury)  36 (8.6)  Positive findings  383 (91.4)   Pneumothorax  235 (56.1)   Pleural effusion  255 (60.9)   Air–fluid level  18 (4.3)   Pneumomediastinum  3 (0.7)   Lung contusion  79 (18.9)   Rib fractures  19 (4.5)   Shrapnels  76 (18.1)  CXR: chest X-ray. After initial screening CXRs, 207 patients (49.4% of imaged patients) underwent chest CTs, and 98.1% of those (n = 203) had had positive signs of injury on initial screening CXRs. Chest CTs confirmed CXR-positive findings in all cases, whereas it revealed 23 previously unidentified injuries in 11.1% of patients (Table 4). Table 4: Additional chest CT findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12      Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12    CT: computed tomography. Table 4: Additional chest CT findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12      Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6  4  2    Pneumothorax  5  2  3    Haemothorax or pneumothorax  4    4    Pulmonary contusion  4  4      Haemothorax + pulmonary contusion  3  1  2    Haemothorax or pneumothorax + pulmonary contusion  1    1    Total  23  11  12    CT: computed tomography. Based on the positive findings on initial screening CXRs (n = 383), decision was made to continue with conservative medical management in 36.1% of patients (n = 138), whereas closed chest drainage was considered in 37.6% of patients (n = 144), and open thoracotomy was performed in 26.3% of patients (n = 101). The additional findings on chest CT led to further therapeutic interventions (which was closed chest drainage) in 12 patients with newly identified haemothorax or pneumothorax. On the other hand, chest CT findings had no impact on patient treatment strategy in 94.4% of scanned patients (Table 4). Follow-up CXRs were performed in all patients on a daily basis until discharge, and new positive findings were noted in 22 patients (Table 5). Based on these findings, additional closed chest drainage was performed in 3 patients, and delayed open thoracotomies were performed to remove shrapnels located close to the aorta or lung hilum in 3 cases and to evacuate blood clots that trapped the lungs in 4 other patients. Table 5: Additional delayed CXR findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7    Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7  CXR: chest X-ray. Table 5: Additional delayed CXR findings and their impact on treatment   Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7    Total number  Method of treatment   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  6    2  4  Pneumothorax  6  6      Haemothorax or pneumothorax  2  1  1    Pulmonary contusion  5  5      Critically located shrapnels  3      3  Total  22  12  3  7  CXR: chest X-ray. Of 449 patients with penetrating war injuries to the chest, 32.3% of patients (n = 144) were managed conservatively, closed chest drainage was performed in 42.5% of patients (n = 191), whereas open thoracotomies were performed in 25.2% of patients (n = 114) (Table 6). Associated extrathoracic injuries were present in 24.9% of patients [including splanchnic (n = 88), limb (n = 48), central nervous (n = 20) and vertebral injuries (n = 13)] and were managed according to standard protocols. The median hospital stay was 7.53 days (lower quartile = 4.89, upper quartile = 11.87), admission to the high-dependency unit was required in 15.4% of patients and artificial ventilation was indicated in 6.7% of patients for a median of 5.9 days (lower quartile = 4.11, upper quartile = 10.23). The overall in-hospital mortality rate was 8.4% (n = 38). Table 6: Distribution of methods of treatment according to types of intrathoracic injuries   Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)      Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)    Table 6: Distribution of methods of treatment according to types of intrathoracic injuries   Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)      Method of treatment/intervention, % (n)   Observation  Closed chest drainage  Open thoracotomy  Haemothorax  9.8 (26)  70.6 (191)  19.6 (53)  Pneumothorax  3.6 (9)  74.9 (184)  21.5 (53)  Pulmonary contusion  100 (88)      Diaphragmatic rupture      100 (46)  Rib fracture  100 (19)      Cardiac injury    8.4 (1)  91.6 (11)  Pneumomediastinum  66.6 (2)  33.3 (1)    Great vessels injury      100 (2)  Oesophageal injury    100 (1)    COMMENT Despite the high diagnostic accuracy of CXRs in detecting major intrathoracic injuries [8], some investigators have highlighted that potentially life-threatening intrathoracic injuries may not be observed using CXRs because blood and air accumulation may be limited or delayed and an intact mediastinal or parietal pleura can stop blood from reaching the pleural cavities where it will be more discernable [9]. Moreover, studies have shown enhanced sensitivity of chest CTs over CXRs in patients presenting with blunt trauma to the chest and that chest CTs can reveal underestimated or overlooked injuries [10–12], with a positive influence on clinical management in many patients [11, 13], and an improvement in their outcomes [5, 6]. Medical practice recommendations at times of war frequently differ from everyday practice guidelines as several distinctive considerations must be taken into account at times of military conflicts. Pertinent to the present discussion, it would be impracticable to perform chest CTs in all patients with penetrating war injuries to the chest since hospital facilities would frequently be overburdened with casualties, in addition to the potential for misuse of the de facto limited medical resources. Further imaging, extended in-hospital stays, unnecessary invasive interventions such as closed chest drainage and unwarranted admissions to high-dependency units can all be consequences of managing findings of uncertain clinical importance. Hence, it would be very helpful to determine whether identification of additional injuries by chest CT will have a positive impact on the choice of therapeutic interventions and clinical outcomes in patients with penetrating war injuries to the chest. This review shows that initial screening CXRs in patients with penetrating war injuries to the chest are capable of revealing the majority of important intrathoracic injuries and that absence of positive signs of injury on initial screening CXRs excludes the presence of any damage in most patients. Although chest CT identified additional injuries (mainly haemothorax or pneumothorax and lung contusions) in approximately 11% of our patients, it is unlikely that these injuries would have been overlooked if chest CT was not done as they would likely have been detected on follow-up CXRs anyway [14, 15]. Moreover, the clinical significance of CT findings was very limited because they had no impact on patient treatment strategy in 94.4% of scanned patients, and there is evidence for the conservative management of small haemothorax or pneumothorax not apparent on initial screening CXRs [16, 17]. This understanding is reinforced by recent studies which indicated that chest CTs after abnormal CXRs rarely detect overlooked clinically significant injuries [10, 18, 19] and that chest CT findings are associated with only limited clinical consequences [2, 10]. On the basis of our experience, we believe that chest CTs can be omitted in most patients with penetrating war injuries to the chest, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized. Identifying injured patients who are expected to benefit from additional imaging with CT of the chest is important and requires larger reviews. Possible indications for performing chest CT may include defining projectile paths to help in planning surgical interventions and identification of damage caused by transmediastinal projectiles that may prove lethal if left untreated [7, 20–22]. Limitations This study does have several limitations. Data were collected retrospectively, and only half of all patients underwent chest CTs as discretion was left to the individual physician, which may have resulted in a selection bias. As a result, it was not possible to estimate the actual sensitivity and specificity of chest CT in detecting intrathoracic damage. CONCLUSION In conclusion, we consider initial screening and delayed CXRs to be the primary diagnostic modality in the assessment and follow-up of patients with penetrating war injuries to the chest, whereas we believe that chest CT scanning should only be used selectively in this group of patients. Also, our experience shows that the majority of patients with penetrating war injuries to the chest can be managed non-operatively, with only a small subset of patients requiring surgical intervention. Conflict of interest: none declared. REFERENCES 1 Traub M, Stevenson M, McEvoy S, Briggs G, Lo SK, Leibman S et al.   The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury  2007; 38: 43– 7. 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Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: May 2, 2018

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