DOI: https://doi.org/10.21203/rs.3.rs-1930712/v1
Globally, Chest trauma is one of the major contributors of morbidity and mortality among trauma patients. There are different studies conducted in Ethiopia about the prevalence of chest injury and overall trauma mortality but not mortality related to chest trauma. Therefore this study aimed to assess the magnitude of chest trauma mortality and associated factors among adult patients admitted at University of Gondar Comprehensive Specialized Hospital, North West Ethiopia, 2019.
out of a total of 400 chest trauma patients about 7.2%( 95% confidence interval (CI) 4.8, 10.0) of them were died. Being aged [Adjusted odds ratio (AOR) = 3.52(1.46, 8.48)], having associated injury [AOR = 4.23(1.49, 12.01)], late presentation [AOR = 2.93(1.22, 7.04)] and having complications [AOR = 4.43(1.9, 10.3)] were significantly significant with chest trauma mortality.
Chest trauma implies trauma to different structures of the chest wall and the chest cavity and affects lung ventilation and/or oxygenation capacity(1, 2). It is one of the major contributor of morbidity and mortality among trauma patients all across the world and one of the most severe injuries of the chest(3, 4). Evidence showed that Chest trauma is worsened along with growing urbanization and industrialization; due to worldwide increases in violence, constructions and vehicle number (5).
Chest trauma is the third important cause of mortality and morbidity preceded by cancer and cardiovascular diseases(6, 7). It accounts significant number of surgical patients’ admissions and younger population are mainly affected (8–10).In addition, it peaks in the productive age groups where economic implications are maximal(11). Even though there are advanced management of trauma and critical care have been recognized, chest trauma still continues to be a significant cause of morbidity, mortality and hospitalization(12, 13).
Globally, 10% of all trauma admissions and 25% of trauma-related deaths are due to chest trauma(10, 14).The mortality rate of patients having chest trauma ranges between 4% and 20% worldwide(15).In Europe and United states, the mortality rate as a result of blunt trauma can be as high as 60%(16).
A research done in South Africa showed that chest trauma is responsible for 27.4% of trauma-related deaths in (17). From a total of 230 road traffic accident victims chest trauma accounts for 13.9% of road traffic related injuries in Ethiopia(18). Besides, a study conducted in Zewditu memorial hospital Ethiopia revealed that chest region is the fourth mostly affected area by road traffic accident and accounts for 9.5% of all body region injured as a result of road traffic accident (19)
Studies showed that the main cause of chest trauma were road traffic accident, fall down injury, stab injury and gunshot (20–22).
Though chest injury can cause a serious and fatal problem, it can be reduced by identifying the cause of chest injury. These is done by giving intervention focused to the underlying cause such as improving road safety ; implementation of strict traffic laws enforcement ( like seat belt); and educating people about traffic rules and regulations (23, 24). Once after the event happened, appropriate and timely diagnosis of chest traumas can decrease the mortality and morbidity(25).
There are studies conducted in Ethiopia on magnitude of chest trauma and overall trauma mortality but not mortality related to chest trauma.
Therefore, this study fills information gap about magnitude of chest trauma mortality and associated factors among adult patients admitted at University of Gondar Comprehensive Specialized Hospital, North West Ethiopia.
Institution based cross sectional study was conducted and the study was conducted from March 1st to May 30 2019. The study was conducted at Gondar University Comprehensive Specialized Referral hospital. It is the only Comprehensive Specialized Referral hospital in Gondar town serving for a total of five million people of the north Gondar zone and the neighboring zones. Gondar town is located in North Gondar administrative zone, Amharic National Regional state, Ethiopia which is about 727 km Northwest of Addis Ababa (the capital city of Ethiopia). According to the 2007 population and housing census report, the total population size of Gondar town was estimated to be 206, 987. All adult chest trauma patients admitted at UOGCSH were the source of population for this study while all adult chest trauma patients admitted at UOGCSH from January1st 2016 to December 30/2019 were the study populations
All adult chest trauma patients admitted at UOGCSH from Jan1st 2016 to Dec 30/2019 were included in this study while Patients’ having incomplete information were excluded.
Te sample size was determined by using single population proportion formula with the assumption of 95% level of confidence, 5% marginal error, and by taking 50% prevalence (since the study was not done in Ethiopia previously). By considering 10% non-response rate, the final sample size was 422. Systematic random sampling technique was conducted to get study units from chest trauma patients admitted at university of Gondar Hospital. For a period of four years, from Jan1st 2016 to Feb.30/2020, a total of 902 adult patients with chest trauma were registered. Thus, by using systematic random sampling technique, the sampling interval “K” value is calculated as K = N/n, where N = total number of patients with chest injury within four years = 902 and n = final sample size = 422. Therefore, k = N/n = 902/422 = 2.1 = 2. Then, by using patients’ Medical Record Number (MRN) which is listed in the log book as a sampling frame a lottery method was used from 1-k i.e. 1 & 2 to get the first participant (The number was 1). Therefore, every kth = 2nd interval study subjects (charts) were selected until the sample size of 422.The data were collected using a pre-tested and structured data extraction checklist adapted from different literature (10, 11, 15, 21, 27). The checklist was developed in English language and contains five parts to extract relevant information such as sociodemographic characteristics of the participants, injury related factors, patient condition at admission, treatment modality related factors and co-morbid diseases. Medical record number of patients with chest trauma was retrieved from log book of minor and major operation room. After collecting a four year registration the study participants were selected by using systematic random sampling. Then the patients chart was addressed from chart room and data were collected using data extraction check list. Data were collected bythree BSc nurses and was supervised by one MSc Nurse. Different measures were taken in order to assure the quality of the data.The first measure was giving training for data collectors and supervisor on data collection technique for a day. Pretest was done on 5%( 21) of the charts in order to test the clarity in University of Gondar Comprehensive Specialized Hospital. After the pre- test, corrective measures were taken. During the data retrieval process, regular monitoring and supervision of the overall activity was done by both supervisor and principal investigator to check for completeness and ensure the quality of data. Besides, the collected data were reviewed and checked for completeness before data entry. After the data were checked for its consistency and completeness, it was coded and entered to EPI- INFO version 7.2.1.0 and exported to SPSS version 23 for further analysis. Descriptive statistics was presented by frequency and percentage. Binary logistic regression was done to see the crude significant association of each independent variable with dependent variable. Then variables with p-value less than and equal to 0.25 were entered to multivariable analysis. The Hosmer and Lemeshow test were used to diagnose the model adequacy. Variables which were failed at the chi-square test and Fisher exact test were removed from multiple logistic regression analysis. Finally, those variables with a p-value of less than/equal to 0.05 was found to be statistically significant. The strength of association was expressed by adjusted odds ratio (AOR) with 95% confidence interval and p-value.
A total of 422 charts were reviewed in this study. From those 94.8% were included in the analysis where as 5.2% are incomplete. Among these, more than three fourth of participants (78%) were males and the mean age of respondents was 33.91 (± standard deviation (SD) of 13.079) years.
Regarding their place of residence, two-hundred and fifty-one (62.7%) of patients were came from rural area, and 82.8% of them were arrived within 24 hours after injury (Table 1).
| Characteristics | Categories | Frequency | Percent |
|---|---|---|---|
| Age | 18–45 | 323 | 80.75 |
| 46–80 | 77 | 19.25 | |
| Sex | Male | 312 | 22.0 |
| Female | 88 | 78.0 | |
| Residency | Urban | 149 | 37.3 |
| Rural | 251 | 62.7 | |
| Time of arrival(hour) | ≤ 24 | 331 | 82.75 |
| > 24 | 69 | 17.25 |
A total of 56(14%) of patients who sustained chest trauma had co-morbid chronic disease, and diabetic mellitus (6.3%) was the commonest co-morbid disease followed by Asthma (3.5%). Regarding patients’ condition at admission, 102 (25.5%) and 173(43.3%) of them had pulse rate of > 100b/m and a respiratory rate of > 20br/m respectively. (Table 2).
| Variables | Frequency | Percent |
|---|---|---|
| Co-morbid illness | ||
| Diabetic mellitus | 25 | 6.25 |
| Asthma | 14 | 3.5 |
| Cardiovascular disease | 13 | 3.25 |
| Other premorbid diseases(RVI,kidney disease | 7 | 1.75 |
| Patient condition at admission | ||
| Systolicbloodpressure | ||
| < 103 | 184 | 46.0 |
| ≥ 103 | 216 | 54.0 |
| Pulse rate (beats/min) | ||
| 60–100 | 277 | 69.25 |
| < 60 | 21 | 5.25 |
| > 100 | 102 | 25.5 |
| Oxygen saturation (%) | ||
| < 95 | 156 | 39.0 |
| ≥ 95 | 244 | 61.0 |
| Temperature | ||
| 36.5–37.5 | 199 | 49.75 |
| < 36.5 | 186 | 46.5 |
| > 37.5 | 15 | 3.75 |
| Respiratory rate(br/m) | ||
| 12–20 | 218 | 54.5 |
| < 12 | 9 | 2.25 |
| > 20 | 173 | 43.25 |
| GCS at admission | ||
| < 13 | 14 | 3.5 |
| ≥ 13 | 386 | 96.5 |
| (RVI: Retroviral Infection; GCS: Glasgow Comma Scale) | ||
Road traffic accident was the most common cause chest trauma followed by bullet injury, which accounts for 34.5% and 25% cases respectively. Associated extra-thoracic injuries were noted in 53.5% of patients and abdominal injury (30.0%) and head injury (17.0%) were commonly affected. Hemopneumothorax, thoracoabdominal injury and haemothorax were the most common diagnosis accounting for 34.5%, 30.0% and 18.3% respectively. Most of (88%) study participants had unilateral chest trauma and majority (57.25%) of patients had blunt chest trauma. 32(8%) were developed complication after trauma and pneumonia was the most common. (Table 3).
| Variables | Frequency | Percent |
|---|---|---|
| Mechanism of chesttrauma | ||
| Road traffic accident | 138 | 34.5 |
| Stab injury | 69 | 17.25 |
| Bullet injury | 100 | 25.0 |
| Fall down injury | 79 | 19.75 |
| Other(stone,oxinjury,stick,blast) | 14 | 3.5 |
| Associated injury | ||
| Head injury | 68 | 17.0 |
| Neck injury | 17 | 4.25 |
| Abdominal injury | 120 | 30.0 |
| Spinalcordinjury | 4 | 1.0 |
| Upperextrimityinjury | 29 | 7.25 |
| Lowerextrimityinjury | 26 | 6.5 |
| Other(face, eye) | 10 | 2.5 |
| Clinical Diagnosis | ||
| Pneumothorax | 55 | 13.75 |
| Haemothorax | 73 | 18.25 |
| Hemopneumothorax | 138 | 34.5 |
| Pulmonary contusion | 26 | 6.5 |
| Thoracoabdominal | 120 | 30.0 |
| Chest wound | 52 | 13.0 |
| Rib fracture | 57 | 14.25 |
| Cardiac injury | 12 | 3.0 |
| Aortic injury | 5 | 1.25 |
| Diagrammatic injury | 15 | 3.75 |
| Other(esophageal injury, sternal injury) | 16 | 4.0 |
| Side of chest involvement | ||
| unilateral | 352 | 88.0 |
| bilateral | 48 | 12.0 |
| Types of chest trauma | ||
| blunt chest trauma | 229 | 57.25 |
| penetrating chest trauma | 171 | 42.75 |
| Complication | ||
| Woundsepsis | 8 | 2.0 |
| Pneumonia | 32 | 8.0 |
| Hypovolumicshock | 15 | 3.75 |
| Atelectasis | 6 | 1.5 |
| Other(Anemia,ARDS, septicshock,sucutanious emphysema) | 13 | 3.25 |
| (ARDS: Acute Respiratory Syndrome) | ||
As regards to the various treatment options for the chest trauma, 75.5% were treated by surgical while 24.5% medical treatment. Nearly half of (49.5%) the study participants were admitted from 3–7 days in the Hospital; and 9(2.3%) were admitted in ICU (Intensive Care Unit) (Table 4).
| Variables | Frequency | Percentage |
|---|---|---|
| Medical treatments | ||
| Maintenance fluid | 240 | 60.0 |
| Antipain | 353 | 88.25 |
| Antibiotic | 255 | 63.75 |
| TAT | 85 | 21.25 |
| Chest physiotherapy | 53 | 13.25 |
| Other(transfusion,INo2,antiphycotic drug) | 15 | 3.75 |
| Surgical treatment | 302 | 75.5 |
| Length of hospital stay | ||
| ≤ 2 days | 152 | 38.0 |
| 3–7 days | 198 | 49.5 |
| >=8 days | 50 | 12.5 |
| ICU admission | 9 | 2.3 |
| Pre hospital care | 60 | 15.0 |
| (INo2: intra nasal oxygen, ICU: intensive care unit, POP: plaster of Paris, TAT: tetanus Antitoxoid) | ||
4.5. Magnitude of mortality and associated factors.
The result of this study showed that a total of 29(7.2%) of patients with chest trauma were died.
On Bivariable logistic regression age, premorbid disease, associated injury, haemothorax, thoracoabdominal, rib fracture, time of arrival, and complication were associated with mortality of chest trauma patients(p ≤ 0.25).
However, in the multivariable logistic regression analysis age, associated injury, complication and time of arrival were significantly associated with mortality of chest trauma patients.
The current study identifies chest trauma patients with the age group of > 45 years were almost four times [AOR = 3.5; (95% CI: 1.46, 8.48); p = 0.005)] more likely to die than the age of 18–45 years. Patients with associated injury were [AOR = 4.23 ;( 95% CI: 1.49, 12.01); p = 0.007)] four times more likely to die than patients having isolated chest trauma. Patients develop complications like wound sepsis, pneumonia, atelectasis and hypovolumic shock were [AOR = 4.43 ;( 95% CI: 1.9, 10.3); p = 0.001)] four times more likely to die than patients who have no developed complication. Study participants who were arrived after 24 hrs of the occurred were almost three times [AOR = 2.93 ;( 95% CI: 1.22, 7.04); p = 0.017)] more likely to die than arrived within 24 hours and. (Table 5).
| Variables | Categories | Died Yes No | COR(95% CI) | AOR(95% CI) | P-value | |
|---|---|---|---|---|---|---|
| Age(years) | 18–45 | 16(55.2%) | 307(82.7%) | 1 | 1 | |
| > 45 | 13(44.8%) | 64(17.3%) | 3.89(1.79,8.50) | 3.5(1.46,8.48)) | .005 | |
| Co-morbid illness | Yes | 9(31.0%) | 47(12.7%) | 3.10(1.33,7.22) | 1.43(0.55,3.73) | |
| No | 20(69.0%) | 324(87.3%) | 1 | 1 | ||
| Associated injury | Yes | 24(82.8%) | 190(51.2%) | 4.57(1.71,12.24) | 4.23(1.49,12.01) | .007 |
| No | 5(17.2%) | 181(48.8%) | 1 | 1 | ||
| Haemothorax | Yes | 10(34.5%) | 63(17.0%) | 2.57(1.14,5.79) | 2.22(0.9,5.6) | |
| No | 19(65.5%) | 308(83.0%) | 1 | 1 | ||
| Thoracoabdominal injury | Yes | 13(44.8%) | 107(28.8%) | 2(0.93,4.31) | 1.36(0.49,3.63) | |
| No | 16(55.2%) | 264(71.2%) | 1 | 1 | ||
| Rib fracture | Yes | 7(24.2%) | 50(13.5%) | 2.04(0.83,5.03) | 1.39(0.45,4.32) | |
| No | 22(75.9%) | 321(86.5%) | 1 | |||
| Complication | Yes | 14(48.3%) | 55(14.8%) | 5.36(2.45,11.73) | 4.43(1.9,10.3) | .001 |
| No | 15(51.7%) | 316(85.2%) | 1 | 1 | ||
| Time of arrival(hours) | ≤ 24 | 17(58.6%) | 314(84.6%) | 1 | 1 | |
| > 24 | 12(41.4%) | 57(15.4%) | 3.89(1.76,8.58) | 2.9(1.22,7.04) | .017 | |
| (P is statistically significant at p ≤ 0.05 level of significance) | ||||||
Chest trauma is one of the major contributors of morbidity and mortality among trauma patients. Accordingly, out of the total of admitted chest trauma patients, the magnitude of chest trauma mortality was 7.2% (95% CI: 4.8%, 10%). This finding is consistent with the studies done in united Arab Emirate (7.2%)(15), Iran 7.1% (27), Yemen (5.5%)(18) western UP (6.4%)(3), and Nigeria (5.4%)(11).
However, the finding of the present study is higher than the studies done in Syria (1.8%)(24), Chit wan Nepal (3%)(28), Tanzania (4.7%)(10), Nigeria (2.56%)(26) and Sudan (2%)(20).
The possible justification for being higher might be due to discrepancy in sample size, difference in study population as the above populations; ; difference in early arrival of the patient in the Hospital (97% arrived within 24 hours in Nepal study while 82.8% in this study); disparity in associated injury (36% in Syria while 53.5% in this study); divergence in development of complication (10.7% in Sudan while 17.3% in this study); difference in prehospital care (21.3%,in Tanzania,whereas15% in this study) even though presence of pre-hospital care did not significantly associate with mortality in this study. Difference in the study setting and health care system as the above countries (Syria is developed countries).
On the other hand the finding of this study is lower than the studies done in England (35.6%)(2), India(20.84%)(21) and Tanzania (24.4%)(8). The possible justification for being lower might be due to difference in sample size (large sample size) in the above studies. Study in India and Tanzania showed that 95% and 61.3% of the study participants have associated injury respectively while 53.5% in this study; difference in study design (unlike this study cohort follow up in Tanzania); difference in study time, study setting Unlike in this (four years) study the above studies undergone chart review for many years (11 years in England).
In this study age, associated injury, complication and time of arrival were significantly associated with chest trauma mortality.
The current study revealed that there was a positive relationship between being old age and mortality of chest trauma patients. This is supported by the study done in Germany, Turkey, Massachusetts and England(29–31).As the age increase the patient comes with preexisting medical condition and diminished physiologic reserve (immunity) that inability to compensate for trauma and susceptible to pulmonary deterioration and often affected by other complications such as pneumonia(32).As age increase the thoracic cage is more prone to costal and sternal fractures resulting in severe injuries to internal organs, which may be lethal(33).
Associated injury and mortality of the study participants were found to be positively associated. This is similar with the studies done in Uganda(34), Nigeria(11), Tanzania(10), and Qatar(35) stated as the presence of associated injuries were significantly associated with mortality in chest trauma patients. This might be due to the reason that associated injuries may increase the risk of complications like hemorrhage, infection and others.
The result of this study also showed that there was a positive relationship between having complication after chest trauma (pneumonia, wound sepsis, atelectasis and hypovolumic shock) and mortality of study participants. This is similar with studies done in Tanzania(10) and Uganda(34)stated as presence of complications due to chest injury was significantly associated with mortality in chest trauma patient. This might be due to the reason that patients having complications after chest trauma might relatively have poor prognosis than others who did not have complications.
Being late arrival in the Hospital after injury and death of chest trauma patients were positively associated. This is supported by studies done in Nigeria stated that delayed presentation with injury beyond 24hrs was significantly associated with mortality in chest trauma victim (11). This might be due to the reason that as chest trauma patient delayed for presentation at Heath institutions after an event, the patient might be exposed for Hemorrhage, complications (sepsis) and others may lead the patient for death.
Shortage of similar studies carried out in Ethiopia makes the comparison and discussion difficult.
Since the data was secondary /chart review/, there was missing of variable in the chart. (religion, marital status, occupation, time of treatment started, alcoholic behavior, smoking habit)
The magnitude of mortality of chest trauma patients was found to be high in the study area and being old age group, having extra thoracic injury involvement, development of complication after chest trauma and delayed presentation of the study participants in the hospital after injury were found to be positively associated with the mortality of chest trauma patients.
| ARDS | Acute Respiratory Distress Syndrome |
|---|---|
| AOR | Adjusted Odds Ratio |
| CI | Confidence Interval |
| COR | Crude Odds Ratio |
| DM | Diabetes Mellitus |
| GCS | Glasgow Comma Scale |
| ICU | Intensive Care Unit |
| INO2 | Intranasal Oxygen |
| POP | Plaster Of Paris |
| RVI | Retroviral Infection |
| SPSS | Statistical Package For Social Sciences |
| TAT | Tetanus Anti Toxoid |
| UOGCSH | University Gondar Comprehensive Specialized Hospital |
Data Sharing Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request
Ethical approval and consent to participate: Ethical clearance was obtained from the institutional ethical review board of Gondar University and the supporting letter was obtained from University of Gondar hospital. Confidentiality of the participants’ information was maintained by anonymous data. Informed consent was not taken directly from the study participants as it is completely secondary data.
Consent of publication: Not applicable
Availability of data and materials: Data will be available upon request from the corresponding author.
Funding: This research didn’t receive any grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgment: The authors acknowledged University of Gondar for support and facilitating of this study. The authors also acknowledged study participants and data collectors
Authors’ Contribution: WK, AT and LM worked on the conception of the research idea, designing the study, involved in proposal writing, analyzed and interpreting the results and preparing the manuscript. All authors involved in editing and approving the final manuscript.
The authors declare that they have no competing interests.