Profile of Torso Trauma Following Road Traffic Accidents

Introduction

Trauma is the leading cause of increased morbidity and mortality among individuals aged 1 to 44 years. Torso trauma includes the thoracic and abdominal trauma, excluding head and limbs. Torso injuries are the most dangerous types of injuries leading to mortality.^1,2 The most common injuries include car accidents, pedestrian injuries, falls and sports injuries. In the recent years, the incidence of violence has increased due to factors such as population growth, urbanization, construction, and increased traffic.^1,2,3

The majority of injuries are caused by blunt trauma. Blunt trauma results in severe injuries due to compression, deceleration, or crushing motions in the thoracic and abdominal cavity (torso). Penetrating trauma is rare and mostly results from gunshot or stabbing.^1,4,5

Most of the thoracic trauma patients present respiratory distress.5,6 Chest X-ray, ultrasonography chest (USG), computed tomography (CT) chest, electrocardiogram (ECG), 2-D echocardiogram are the tools used in the diagnosis of thoracic trauma.^4-6

Abdominal ultrasonography (USG), Focused Assessment with Sonography for Trauma (FAST), computed tomography scans, laparoscopy, diagnostic peritoneal lavage (DPL) are the modalities aiding in the diagnosis of abdominal trauma.^7-9

Management of trauma has shifted significantly toward non-operative approaches in recent years, due to advancements in imaging and improvements in critical care.^10-13 Penetrating trauma is less common and often requires surgical intervention.^11,12

Knowledge of factors such as the nature, mechanism, mode and type of injury is crucial as it aids in diagnosing specific injuries and plays a key role in determining the prognosis. Hence, this study aimed to identify the factors in trauma that contribute to improving survival.

Materials and Methods

This retrospective cross-sectional study was conducted at a tertiary care centre, over a six-year period, from April 2018 to March 2024. Local Ethical Committee clearance was taken for the same. Retrograde details of all patients who presented with abdominal trauma or thoracic trauma resulting from road accidents were extracted from case files spanning April 2018 and March 2024. Patients diagnosed with abdominal trauma or thoracic trauma on X-ray radiograph and/or ultrasound (USG) and/or computer tomography (CT), with a history of road traffic accident were included in the study. Patients with associated head injuries, spine injuries, limb injuries, assaults, falls, burns and patients with multisystem injuries were excluded.

The demographic details, mechanism, mode, nature of the injury, symptoms at presentation, stability of patients, investigations done (USG and CT scan reports), definitive treatment either conservative or surgical and the outcomes were collected from the case files and analyzed.

Descriptive and inferential statistical analysis was conducted. Results on continuous measurements were presented as mean±SD (Min-Max) and results on categorical measurements were presented in percentiles. Statistical software IBM SPSS 24.0.(IBM, Armonk, NY, USA) was used for the analysis of data.¹⁴

Results

A total of 500 trauma patients met the inclusion criteria, comprising 390 males (78%) and 110 females (22%) with a male to female ratio of 3.5:1. The patients’ ages ranged from 6 months to 70 years, with a mean age of 36.61±15.61 years (Table 1).

In our study, injuries caused by four-wheeler vehicles were the most common type of road traffic accident-related trauma, accounting for 38% (190/500) of cases, followed by those involving heavy vehicle at 33.4% (Table 2).

About 189 (37.8%) cases reached the hospital six hours after the injury. Around 97 cases (19.4%) presented to the hospital in an unstable condition. Additionally, 118 (23.6%) patients required blood products transfusions, with 107 requiring packed red blood cells (PRBC) and 11 requiring fresh frozen plasma (FFP) transfusion.

Among the trauma patients, 388 (77.6%) had blunt trauma, 25 (5%) had penetrating trauma, and 87 (17.4%) presented with superficial injuries (Table 3).

In our study, chest injuries constituted 67% (335) and abdominal injuries 11.4% (165). Among the 165 cases of abdominal trauma, spleen was the most frequently injured solid organ, observed in 105 cases (63.6%), followed by liver injuries seen in 82 cases (49.7%). Among hollow viscous injuries, bowel injuries were the most common, occurring in 25 cases (15.2%), while kidney injuries were rare, seen in only two cases (0.4%) (Table 4).

About 335 patients had thoracic injuries, among which haemo-pneumothorax was the frequent presentation seen in 98 patients (29.3%), only pneumothorax was seen in 96 (19.2%), hemothorax in 52 (10.4%) patients and soft tissue injuries were seen in 89 cases (17.8%).

Surgical interventions were required in 68 cases (13.6%). However, 431 (86.2%) trauma cases were managed conservatively while one patient was referred to higher center. All the 25 patients of traumatic bowel perforation required surgical intervention. Among 25 cases of hollow viscus injuries, four involved stomach, eight involved jejunum, six were ileal injuries, two were caecal injuries, four were splenic flexure of the colon perforation and one was urinary bladder perforation. Surgical intervention in the bowel injuries consisted of simple closure of perforation in 11 patients, resection and anastomosis in 10 patients and stoma in three patients in view of contamination and delayed presentation. Re-exploration was required in two patients who underwent closure of perforation, among which one was jejunal perforation which required resection and anastomosis and the other was of ileal perforation requiring ileostomy. One patient who underwent resection and anastomosis of ileum developed anastomotic leak which was later managed with ileostomy after relaparotomy (Table 5).

Among the 105 patients who suffered splenic trauma, only 23.8% (25/105) patients suffered injury above Grade 4, requiring splenectomy. Only 11% (9/82) of patients of liver injury required surgical exploration in view of persistent hemodynamic instability and underwent repair of liver laceration; all the injuries were above Grade 3. Two patients of Grade 5 renal injury underwent nephrectomy. Repair of urinary bladder injury was required in one patient. None of the cases of pancreatic injury required surgical intervention (Table 5).

In thoracic injuries, thoracotomy-parenchymal and parietal wall repair was done in five patients, laparo-scopic diaphragmatic hernia repair was done in four cases, while rest of the cases were managed conserva-tively (Table 5).

Five (1%) patients with abdominal or thoracic trauma succumbed to their injuries. Factors contributing to increased mortality included late presentation and management beyond six hours observed in three (60%) patients, hemodynamic instability seen in five (100%) patients, the need for transfusion seen in four (80%) patients, higher grade organ injuries in five (100%) patients, and surgical intervention in four (80%) patients. These factors were identified as poor prognostic indicators associated with increased mortality. The site of injury and mechanism of injury are the other factors contributing and determining prognosis in abdominal and thoracic trauma.

Discussion

Torso trauma is one of the main causes of mortality, both in developed and developing countries.^1,15-17 Thoracic and abdominal trauma is more prevalent in males, often attributed to aggressiveness associated with age.^1,2,15-17 Similarly, in this study, a male predominance was observed, with a male to female ratio of 3.5:1 and 72.7% of cases involving males.

Two-thirds of trauma are caused by motor accidents, followed by falls.^1-3,15-17 Only the thoracic and/or abdominal trauma due to road traffic accidents were considered in our study. Four-wheeler accidents were the most common road accidents noted in our study.

Radiography provides rapid initial imaging assessment, supporting the clinical history and examination.^6,7 CT scan chest and abdomen can accurately assess the grade of injury and help in the early diagnosis.^6-9,18 Plain X-ray and/or computed tomography (CT) help in accurate localization and early detection of injuries.^9,10,18

Blunt trauma is the most common mechanism of injury in trauma cases, with an incidence reported between 86-97%, while penetrating trauma is relatively rare.^1-5,10 Similarly, in our study, blunt trauma accounted for 77.6% of cases.

In our study, 19.4% cases were unstable hemodyna-mically at the time of reporting to the hospital and transfusion of blood or blood products was undertaken in 23.6% cases. The initial treatment includes stabilization of the patient with patent airway, breathing, circulation, IV fluid, oxygenation, crystalloid fluids resuscitation, blood or blood products transfusion when required and identification of other injuries after stabilization. Ongoing monitoring of vitals, repeated abdominal examination and urine output measurements are important.^{3,5,6,10,12,19} The management of patients with thoracic or /and abdominal injuries has shifted towards non-operative treatment.¹³ But the management of high-grade trauma is still unclear and depends on other factors like grade of injuries, haemodynamic stability. This non-operative treatment of trauma decreases the operative & postoperative complications and treatment cost. Repeated clinical assessments are required to decide surgical intervention. Late presentation and delayed treatment may rise morbidity and mortality.^{3,5,6,12,13,19,20} Patients with massive hemothorax /haemoperitonium, hemodynamic instability and high-grade injuries required surgical intervention.^12,13,19,20

In our study, 29.3% of patients with thoracic trauma presented with hemopneumothorax. In contrast, other studies reported pneumothorax as the most frequent presentation, followed by hemothorax and hemopneumothorax.^1,4-6,11,16 This presentation occurs simultaneously with injuries to lung parenchyma, ribs and mediastinum. The hemothorax is a marker for severity and mortality due to trauma. Patients with massive haemothorax presents with respiratory distress, hypovolemia and haemorrhagic shock. Tube thora-costomy is required for decompression of thorax and to decide on the need for surgical intervention.^{5,6,11,16,18-20}

In cases of abdominal trauma, the spleen was the most commonly injured solid organ, as observed in 63% cases, followed by liver injuries, which occurred in 49% of cases. Other studies in the literature also reported spleen to be the frequent organ of injury followed by liver.^{1,10,12,13,21} In abdominal trauma, renal trauma was found in 10% to 20% of cases and majority were treated conservatively.^22,23 However, cases with hemodynamic instability and higher-grade renal injury requires surgical intervention.^22,23

Abdominal trauma could be blunt or penetrating. In our study, penetrating abdominal trauma was noted in 5% cases, leading to hollow viscus perforation. The incidence of penetrating trauma is relatively lower in children when compared to adults.^24-26 In the current study, among the cases of penetrating abdominal trauma, 100% patients had traumatic bowel perforation requiring surgery, which can further increase the mortality due to peritonitis resulting from the spillage of the contents and also due to surgical stress. Hence, penetrating abdominal trauma with hollow viscous involvement, requiring surgical intervention can be considered as a poor prognostic factor.^24-26

In this study, we noted that factors like late presentation, hemodynamic instability, transfusion requirement, penetrating injury, high grade of injury, demonstrated poor outcomes. The site, mechanism, and mode of injury were independent factors contributing to outcome in trauma.^{1,2,3,5,10,12,16,17,20,21}

Our study had a few limitations, including being a single-centre study focused on isolated thoracic and/or abdominal trauma. Therefore, multicenter studies are needed to generalize the results.

Conclusion

Factors like late presentation, transfusion requirement, hemodynamic instability, penetrating injury, high grade of injury, surgical intervention have poor outcomes. The site, mechanism, and mode of injury are the additional factors that significantly influence the outcomes in torso trauma.

Conflict of Interest

Nil

Financial support

Nil