Ocena wyników leczenia u chorych z odmą płaszczową - PDF

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ANNALES ACADEMIAE MEDICAE STETINENSIS ROCZNIKI POMORSKIEJ AKADEMII MEDYCZNEJ W SZCZECINIE 2013, 59, 2, Jacek Lorkowski 1, 2, Iwona Teul 3, Waldemar Hładki 2, Ireneusz Kotela 1, 4 The evaluation of

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ANNALES ACADEMIAE MEDICAE STETINENSIS ROCZNIKI POMORSKIEJ AKADEMII MEDYCZNEJ W SZCZECINIE 2013, 59, 2, Jacek Lorkowski 1, 2, Iwona Teul 3, Waldemar Hładki 2, Ireneusz Kotela 1, 4 The evaluation of the treatment results in patients with a small closed pneumothorax Ocena wyników leczenia u chorych z odmą płaszczową 1 Klinika Ortopedii i Traumatologii Centralnego Szpitala Klinicznego Ministerstwa Spraw Wewnętrznych w Warszawie ul. Wołoska 137, Warszawa Kierownik: dr hab. n. med., prof. UJK Ireneusz Kotela 2 Katedra Anestezjologii i Intensywnej Terapii Collegium Medicum Uniwersytetu Jagiellońskiego ul. Kopernika 17, Kraków Kierownik: prof. dr hab. n. med. Janusz Andres 3 Katedra i Zakład Anatomii Prawidłowej i Klinicznej Pomorskiego Uniwersytetu Medycznego w Szczecinie al. Powstańców Wlkp. 72, Szczecin Kierownik: dr hab. n. med. Zbigniew Ziętek 4 Instytut Fizjoterapii Uniwersytetu Jana Kochanowskiego w Kielcach al. IX Wieków Kielc 19, Kielce Kierownik: dr hab. n. med., prof. UJK Ireneusz Kotela Streszczenie Wstęp: Pourazowa odma stanowi poważny problem kliniczny. Celem pracy była analiza sposobów i wyników leczenia chorych z odmą płaszczową. Materiał i metody: Oceniono wyniki leczenia 34 chorych pourazowych hospitalizowanych w latach z powodu odmy płaszczowatej. W grupie tej było 23 mężczyzn i 11 kobiet. Wiek chorych wynosił (średnio 48,5) lat. U 15 chorych uraz dotyczył strony prawej, u 19 strony lewej. W 10 przypadkach odma związana była z urazem wielonarządowym. U 24 chorych w badaniu radiologicznym stwierdzono złamanie 1 7 (średnio 3,4) żeber, u 10 badanie radiologiczne nie wykazało złamanie żebra (u 5 z tych chorych badanie kliniczne wskazywało na złamanie jednego żebra, niewidoczne w obrazie radiologicznym). Wielkość odmy płaszczowej w badaniu radiologicznym klatki piersiowej w projekcji przednio tylnej wynosiła 0,5 2 (średnio 1,2) cm. Wyniki: U 33 chorych doszło do samoistnej resorpcji odmy. U 1 chorego, w związku z jej powiększeniem i pojawieniem się objawów niewydolności oddechowej, konieczne było zastosowanie drenażu jamy opłucnej. W jednym przypadku konieczna była punkcja jamy opłucnej celem ewakuacji krwiaka towarzyszącego odmie płaszczowej. U wszystkich chorych uzyskano dobry wynik leczenia. Wnioski: Zachowawcze leczenie odmy płaszczowej jest w większości przypadków skuteczną metodą leczenia tego schorzenia. H a s ł a: odma zamknięta odma płaszczowa leczenie. Summary Introduction: The aim of this study was to analyze the methods and results of the treatment of patients with a small closed pneumothorax. Material and methods: The results of the treatment of 34 patients hospitalized for trauma in due to a small closed pneumothorax were assessed. There were 23 men and 11 women. The age of the patients ranged from years (av. 48.5). 15 patients had trauma affecting the right side, and 19 had left side trauma. In 10 cases the pneumothorax was associated with multiple trauma. In 24 cases fracture of the ribs (av. 3.4) was revealed in radiological examination. In 10 patients radiographs did not show fracture of the ribs (in 5 of these patients, a clinical trial indicated a fracture of one 44 Jacek Lorkowski, Iwona Teul, Waldemar Hładki, Ireneusz Kotela rib, not visible on x ray). The size of the pneumothorax in chest radiographic anterior posterior projection ranged from cm (av. 1.2). Conservative treatment was monitored through radiological examination. Results: In 33 patients spontaneous pneumothorax resorption was observed. In one patient it was necessary to apply pleural drainage due to the enlargement of the pneumothorax and the appearance of symptoms of respiratory failure. In one case it was necessary to puncture the pleural cavity to remove a hematoma occurring along with the pneumothorax. Good results of treatment were achieved in all cases. Conclusions: In conclusion, the conservative treatment of a small closed pneumothorax is effective in most cases. K e y w o r d s: closed pneumothorax small closed pneumothorax conservative treatment. that is to say also both types of injuries, occur together. In the case of a chest wall injury its severity can range from a single rib fracture to extensive chest wall instability. In some cases, with one or more rib fractures, lung injury and pneumothorax are revealed. A pneumothorax is an abnormal collection of air or gas in the pleural space separating the lung from the chest wall, which may interfere with normal breathing. Closed, open or tension pneumothoraces after injury are recognized. A small closed pneumothorax is the most optimistic patient diagnosis in this case [5, 6, 7, 8]. The aim of this study was to analyze the methods and results of the treatment of patients with a small closed pneumothorax. Material and methods Introduction An injury is a biological phenomenon which people have been dealing with since the beginning of their existence on earth. A French surgeon, Ambroise Paré, formulated the first definition of an injury in This definition describes an injury as any damage to an organism from outside through force and violence, the biting and scratching by beasts, knives, stones, bludgeons, swords, rifles. According to the modern definition an injury is damage to a biological organism which can be classified on various bases. Injuries are classified on the basis of cause, location and activity. Classification by cause distinguishes the following types of injuries: traumatic injury (a body wound or shock caused by a sudden physical injury, in the case of violence or accident), other injuries from external physical causes, such as a radiation injury, a burn injury or frostbite, but it also distinguishes: an injury from infection, an injury from a toxin, or as an adverse effect of a pharmaceutical drug, a metabolic injury (complications of diabetes due to hyperglycaemia and complications of lysosomal sto rage diseases and glycogen), an injury due to autoimmunity, an injury due to cancer, and a secondary injury due to any other disease [1, 2, 3]. The complexity of the clinical problem of trauma has already been indicated in the above classification and definitions. Energy is always taken into account when assessing a traumatic injury which typically acts on the human body. Low energy injuries and a high energy injuries are distinguished. The kinetic energy of an injury (e) of a non rotating object of mass (m) travelling at a speed (v) is: e = mv 2 /2 [4]. The mechanical injury of the chest is one of the most common. In 12.3% of isolated injuries and 47.2% cases of multi organ trauma chest injuries are observed. Chest wall injuries and injuries of internal thorax organs are diagnosed. Chest wall injuries usually occur in the direct mechanism, i.e. due to acceleration phenomenon, and internal visceral injuries occur in the mechanism of deceleration. Frequently, both physical phenomena, i.e. acceleration and deceleration, The results of the treatment of 34 patients hospitalized for trauma in due to a small closed pneumothorax were assessed. There were 23 men and 11 women. The age of the patients ranged from years (av. 48.5). The cause of injury was a fall in 12 cases, there were 10 cases of traffic accident (4 drivers, 6 pedestrians), 1 case of sports injury, 6 cases of assault, and in 5 cases the cause of the injury is not known. All the patients were interviewed and underwent physical examination. Diagnostics were supplemented in each case with a chest X ray. The study was performed in the anterior posterior projection, and after the diagnosis of pneumothorax study they were supplemented with the lateral projection. Diagnostics were also supplemented with routine blood tests. In addition to standard tests (CBC, electrolytes, glucose, urea, APTT, INR) patients arterial blood gases were immediately measured after admission and diagnosis of pneumothorax. Diagnostics was repeated during the patient s stay in hospital. Chest X ray was repeated 1 or 2 days after the injury. Arterial blood gases were additionally checked on day 2 or 3. Examination after discharge from hospital, including X ray, was performed on an outpatient basis about 4 weeks and 6 months after injury. Results In all patients chest pain at the injury site (in the place of a fractured rib or stab wound) was observed in the physical examination. At the time of the admission of the patient no pathological breathing movements of the chest, or explicit reduction in mobility of the chest on one side were revealed, and there were no clearly identifiable auscultatory changes or other signs of respiratory distress. Subcutaneous emphysema in 5 patients was found. Its size did not exceed 5 5 cm. 2 cases of slight chest stab wound were diagnosed. They were small size 2 cm injuries located on the posterior side of the chest. 15 patients had trauma affecting the right side, with 19 cases of left side trauma. In 10 cases the pneumothorax was associated with multiple trauma. The evaluation of the treatment results in patients with pneumothorax 45 Fig. 1. Chest X ray small closed pneumothorax In 24 cases fracture of the ribs (av. 3.4) was revealed in radiological examination. A fracture of individual ribs in the whole study group was found in the following number of cases: fracture of the first rib 2 cases, the second 6 cases, the third 5 cases, the fourth 6 cases, the fifth 12 cases, the sixth 17 cases, the seventh 17 cases, the eight 8 cases, the ninth 6 cases, the tenth 3 cases, the eleventh 2 cases, and the twelfth 1 case. In 10 patients radiographs did not show fracture of the ribs (in 5 of these patients, a clinical trial indicated an obvious fracture of one rib, not visible on x ray). In 2 cases of slight chest stab wound a pneumothorax was confirmed. In 2 cases a small hemopneumothorax was found. The size of the pneumothorax in chest antero posterior radiographic projection was cm (av. 1.2 cm) Figure 1. All patients were initially treated conservatively pleural drainage was not performed. Fractured ribs were locally anesthetized 2 times a day (Lignocaine + Buvocaine) for the first 2 3 days after injury, and then analgesics were administered intravenously or orally. Pulmonary rehabilitation was used from the first day. Stab wounds of the chest were treated in a typical way (stitches), without checking the bottom of the wounds, in order not to increase the pneumothorax. Breathing exercises were performed in all patients during hospitalization and after discharge. Conservative treatment was monitored through radiological examination. There were no significant deviations from the norm in standard laboratory tests and blood gas tests. In 33 patients spontaneous pneumothorax resorption was observed. Firstly, the absorption of the pneumothorax, i.e. the reduction in the size of the X ray image in the first control radiographs, was noticed. The full absorption of the pneumothorax was observed in every case after one month. One patient was an exception. In this case it was necessary to apply the pleural drainage due to the enlargement of the pneumothorax on the first day after the injury, and the appearance of the symptoms of respiratory failure. Short- term oxygen therapy was necessary for this patient. There was a full normalization of respiratory parameters within 2 hours of the drainage of the pleural cavity. The drain was removed after 5 days, and the radiographic check confirmed complete lung decompression. During treatment this patient was diagnosed with radiographic symptoms of lung contusion. Other complications of the respiratory system were not revealed for this patient. In 1 case it was necessary to puncture (ultrasound guided evacuation of the hematoma) the pleural cavity to remove the hematoma (about 200 ml of blood) occurring along with the pneumothorax. The time of hospitalization of patients from the study group was 2 8 days, an average of 3.2 days. Good results of treatment were achieved in all cases. In the first control radiograph the absorption of the pneumothorax was observed the reduction in the size of the X ray image, but after a month the full absorption of the pneumothorax was found in every case. At the approximately 6 month follow up period no recurrence of the pneumothorax or other respiratory illnesses was revealed in these patients. The patients returned to full previous activity, including the younger patients, who returned to sports. The treatment of patients in the study group included other injuries. These injuries included both head traumas and musculoskeletal injuries. A head injury was diagnosed in 14 patients: intracerebral hematoma in one case, brain concussion was diagnosed in 8 patients, and superficial injury of the head was diagnosed in 5 cases. The intracerebral hematoma which was found in one patient did not require surgery, just observation and monitoring, and was present in the implementation of computer tomography scans of the head. Spontaneous resorption of the hematoma lasted a few weeks. The following were diagnosed within the musculoskeletal system in the examined group: 5 cases of spinal injuries (respectively, 1 case of fracture of the body of the cervical spine and 1 of the thoracic spine, 1 case of processus of lumbar vertebrae fractures, 1 case of processus transversus fracture, 1 case of cervical spine sprain, and 1 of contusion of the lumbar spine), 1 case of pelvic fracture (fracture of the iliac crest), and 7 injuries of the upper limbs (2 cases of clavicle fracture, 1 case of scapula fracture, 1 case of fracture of the shaft of the humerus, 1 case of forearm fracture, and 1 case of metacarpal bone fracture). In some cases more than one musculoskeletal injury was evident. 5 patients at the time of injury were intoxicated. Movement system injuries were treated as follows: injuries of the cervical spine were immobilized in Shantz neck braces (2 cases), shoulder girdle injuries were treated conservatively in braces (3 cases), fracture of the humerus was treated in a Caldwell cast (1 case), forearm fracture was stabilized by AO (1 case), and undisplaced metacarpal fractures were immobilized in a plaster dressing (1 case). Complete fracture unions were obtained and full functional recovery of the spine and limbs was achieved in each case. One exception was a deficit of 15 degrees of elbow extension in a patient after a fracture of the humerus. Fractures of the spinous processus and costales processus fracture did not 46 Jacek Lorkowski, Iwona Teul, Waldemar Hładki, Ireneusz Kotela require immobilization but only pain management until the symptoms disappeared. In all patients with musculoskeletal injury rehabilitation procedures were implemented. Full recovery functions for mobility were reached within 5 months. 5 patients at the time of injury were intoxicated. The treatment of this pathology included the treatment of fluids and monitoring of blood parameters within 24 hours after the injury. There were no long term negative consequences of this pathology. Therefore, the treatment of traumas associated with respiratory injury also had good results. Discussion Chest injuries are the third most common (after injuries of the head and lower limbs) isolated injury and include the three most common injuries occurring in multi organ injury [8, 9]. Chest injuries are diagnosed on the basis of case history, physical examination and radiography. The literature also pays attention to the possibility of using ultrasound for the diagnosis of chest pneumothoraces. This is a quick method, harmless to the patient, and allows an easy way for monitoring the patient. A characteristic symptom, also in the study group, is pain in the interview and physical examination that is present on the side of the injury, increasing the respiratory movements. The symptoms of respiratory failure can often be accompanied with extensive injuries [10, 11, 12, 13, 14]. In the study group of patients with a small closed pneumothorax, except for one case of pneumothorax expansion, there were no signs of respiratory failure. The clinical condition of each patient was similar: pain in the place of a fractured rib or damaged chest wall, there was no specific respiratory asymmetry (especially after the administration of analgesics), and no evidence of respiratory failure. In a small group of patients a small subcutaneous emphysema was diagnosed in physical examination. According to the authors experience and information in the literature it is the near pathognomonic symptom which confirms the presence of a pneumothorax [9]. Moreover, the identification of a small closed pneumothorax was based on the radiological examination in each case. The blood gas test results in the study group were not changed. There was no obvious symptom of radiological fracture of the ribs in a significant number of cases (8 of 32 patients). The diagnosis was suggested by the clinical condition. It seems that in these cases we dealt with a fracture of 1 or 2 ribs which resulted in a small closed pneumothorax. It was not necessary to give an accurate diagnosis to confirm the rib fracture in these cases, since it would not affect the therapeutic treatment. 2 cases involved drivers who caused their vehicle airbag to open, and they had 6 or 7 ribs fractured. If the fracture of the ribs was confirmed in radiological tests, there were usually more than 3 ribs fractured generally in our research group. Fractures occur most often near the posterior axillary line. This area extended to the anterior axillary line if the fracture affected more ribs. This is compatible with the literature, which indicates this part of the ribs as the locus of increased overloads and reduced resistance. Firstly, this phenomenon occurs because of the shape of the rib, and secondly, due to the change in the direct vicinity of passage which is the material of the rib cartilage to bone [8, 15, 16]. It is interesting to identify the first rib fractures in 2 cases which, according to the literature, most often involve severe injuries. This occurred despite the fact that our patients were not in a serious condition. It is wrongly suggested that there could be as many as 10 cases of our patients treated with multiple organ injury. However, this was principally due to the fact that a head injury with brain concussion, together with trauma of the chest with a pneumothorax is recognized in accordance with the definition of multi organ injury. In some cases this was accompanied by further trauma to the musculoskeletal system. However, these were not severe injuries. According to the Abbreviated Injury Scale Injury Severity Score or LSO, the scale result was not high [8, 17, 18, 19, 20]. Isolated fractures of the lower ribs were not observed in our study. According to the literature these cases are connected with osteoporotic changes. Each case of fracture of the lower ribs and pain in the rib needed standard FAST ultrasound to exclude abdominal injury and bleeding into the peritoneal cavity. Such consequences of an injury were not observed in any of the patients evaluated by us [19, 21]. The most common cause of a small closed pneumothorax deserves attention. In our material these are de facto trivial trauma, i.e. one level falls. This indicates the need for an accurate examination of patients after this type of injury, because intuitively a pneumothorax is an unlikely consequence of this. A separate group consists of patients after stab wounds to the chest. We probably dealt with impact of the knife on rib in this case, and due to this there were more further severe injuries. This problem is of a sociological rather than medical or social nature. Breathing exercises and analgesia are important therapeutic methods. This allows the full decompression of the lungs, avoiding the creation of emphysema, pneumonia and other complications. In the modern therapeutic procedure bandaging of the chest i
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