International Journal of Surgery Open 37 (2021) 100420

Contents lists available at ScienceDirect

International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Mortality rate and factors associated with death in traumatic chest injury
patients: A retrospective study
Abubeker Eshetu Yimam a, Salh Yalew Mustofa b, *, Amare H/kiros Gebregzi b, Habtu Adane Aytolign b
a
Department of Anesthesia, School of Medicine,College of Medicine and Health Sciences, Debretabor University, Ethiopia
b
Department of Anesthesia, School of Medicine,College of Medicine and Health Sciences, University of Gondar,Gondar, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Traumatic chest injury is responsible for 10%e15% of all trauma-related hospital admissions
Received 11 August 2021 across the world. It is also responsible for approximately 25% of trauma related death. Several predictors
Received in revised form have been described for mortality following chest trauma however, limited published studies were
2 September 2021
available in Ethiopia.
Accepted 6 September 2021
Available online 4 October 2021
Objective: To assess mortality rate and factors associated with death in traumatic chest injury patients
over five year's period from June 2016 to June 30, 2020 G.C.
Method: A retrospective cross-sectional study was done from June 2016 to June 30, 2020. Data was
Keywords:
Chest injury
collected from patients’ chart. The collected data was entered into Epi-info version 7 and transferred to
Mortality SPSS version 20.0 for processing and analysis. Bivariable and multivariable logistic regression was used to
Factors show factors associated with mortality. P- Value < 0.05 was considered statistically significant.
Trauma severity Result: A total of 419 patient charts were eligible for this study. The majority of patients (55.8%) sustained
blunt chest injuries and violence (52.5%) was the leading cause of injuries. Hemopneumothorax (27.7.0%),
hemothorax (22.9%) and rib fracture (17.2%% were the most common type of injuries. Associated extra-
thoracic injuries were noted in 70.4% of patients, from those, extremity injury (22.2%), head/neck injuries
(21.7%) and abdominal injuries (18.1%) were the commonest. Most patients (64.7%) were treated suc-
cessfully with chest tube. Nearly, one third (35.3%) had complications including pneumonia (13.8%) and
Atelectasis (12.6%). The mean length of hospital stay was 9.40 days. The overall traumatic chest injury
mortality rate was 26%. Mortality was significantly associated with age >50 year [AOR 9.32, 95% CI, 2.72
e31.86], late presentation beyond 6hr (AOR 7.17, 95% CI 1.76e29.21), bilateral chest injury (AOR 3.58 95%
CI 1.53e8.38), penetrating chest injury (AOR 3.63 95% CI 1.65e7.98), presence of extra-thoracic injury
(AOR 4.80, 95% CI, 1.47e15.72) and need for mechanical ventilation (AOR 11.18, 95% CI 2.11e59.23).
Conclusion: The mortality rate in traumatic chest injury was high. Late presentation beyond 6hr, age
>50-year, penetrating injury, bilateral chest injury, associated extra thoracic injury, and need for me-
chanical ventilation were identified as possible risk factors for mortality in traumatic chest injury
patients.
© 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

1. Introduction 1.3 million, suicides 844,000, and homicides 600,000 deaths per year.
Even though, about 91% occur in developing countries, it is still major
Traumatic damage is the principal cause of death and disability public health problem in both high and low incomes countries.
worldwide. It happened frequently in first four decades of life. Glob- Trauma negatively affects the health of population regardless of age,
ally 5.8 million people die every year from non-intentional traumatic sex, religion, income and residency[1e3].
injuries and violence. Road traffic accidents were responsible for up to It is also a continuing challenge in Ethiopia, as the magnitude of
injury was seen in Tikur Anbesa Hospital (32%), Dilla University
Hospital (46.6%), in the whole Amhara Regional State (55.6%) and in
* Corresponding author.
one Amhara Regional State hospital (25%). This exposed to a sig-
E-mail addresses: abueshetu90@gmail.com (A.E. Yimam), salihyalew11@gmail. nificant economic and social crisis more than 10% of all disease
com, salihyalew11@gmail.com (S.Y. Mustofa), amaretom22@gmail.com cases[4e8].
(A.H.–g.–> Gebregzi), habituadane@gmail.com (H.A. Aytolign).

https://doi.org/10.1016/j.ijso.2021.100420
2405-8572/© 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Globally Chest trauma is responsible in a rate of 10e15% of all threatening conditions diagnosis and prompt treatment should
traumas related hospital admission. It directly responsible for be started simultaneously. Airway, breathing, circulation (ABC)
approximately 25% of trauma related death. Death caused by management approach is crucial. Patients with minimal pneumo-
traumatic chest injury ranked in third place after head and spinal thorax and minimal hemothorax underwent thoracentesis alone.
cord injuries. Since the chest is a large and exposed area, it is high Indeed, some patients are still requiring thoracotomy. Complica-
likely susceptible for impacted injuries. Even though thoracic cage tions like pneumonia, wound sepsis, and atelectasis are common
is a protective of vital organs like heart, lungs and great vessels [9,23e25].
injury to these organs can prove fatal. Moreover, delayed in inter-
vention and late diagnosis has significant mortality[3,9e12]. 2. Methods and materials
Chest trauma is causing a variety of injuries, ranging from
simple abrasions and contusions to life-threatening insults. Life After ethical clearance was obtained from the institution ethical
threatening conditions explained by the complexity of thoracic review committee, a retrospective cross-sectional study was con-
injuries and related respiratory failure. Trauma to chest results a ducted. Patients diagnosed clinically or imaging or both and those
significant morbidity and mortality in developing countries. received treatment for traumatic chest injury for the last five years
Growing of urbanization and creation of high-speed motor vehicles period from June 2016 to June 30, 2020G.C. were enrolled in the
has resulted in enormous increase in the number of traumatic chest study. Data was collected by using patient chart review. The list of
injuries[9,12,13]. patients diagnosed with traumatic chest injury was identified from
Chest injury is a powerful indicator of pulmonary deterioration patient registry of the hospital emergency department. Then, the
and complications. The risk of complication is greatest in older records of each patient were accessed from record office based on
population with increased ventilator days, pneumonia and acute the identified list. Finally, it was evaluated and reviewed manually
respiratory distress syndrome when compared with younger ages. for its eligibility to meet the required inclusion criteria. This study
Another mark of severity of chest trauma is bilateral chest registered at http://www.researchregistry.com Research Registry
involvement. So, nearly 50% of mortality occurred among the pa- UIN: researchregistry7105 and reported according to STROCSS
tients who suffered bilateral chest involvement[14e16]. criteria [41].
Both blunt and penetrating chest trauma can result mortality.
Even though, in most series blunt chest trauma occurs more 2.1. Inclusion criteria
frequently than penetrating chest trauma. Most of the time blunt
chest trauma will be caused by motor vehicle accident, fall down All patients diagnosed clinically and/or imaging for chest injury
and crush injuries. While penetrating chest trauma can be caused and received treatment from June 2016 to June 30, 2020G.C. were
by gunshot, stab and blast injuries[14,17]. included.
The pattern and causes of chest injuries reported in literatures
may vary from one country to another part of the world because of 2.2. Exclusion criteria
variations in infrastructure, civil violence, war, crime and applica-
bility of traffic rules and regulations[18]. Missed or incomplete chart documents, patients who died
In Ethiopia, trauma is still public health problem. For instance, immediately at the time of their arrival to the hospital before
death rate in emergency department from traumatic chest injury receiving healthcare and those referred to other centers after
was 30.1% at Tikur Anbessa Specialized Teaching Hospital. Another admission were excluded.
study in this Hospital on road traffic related chest injury accounts
13.9%. Additionally, chest injury caused by RTA responsible 9.5% at 2.3. Dependent variables
Zewditu Memorial Hospital and 9.7% Ayder Referral Teaching
Hospital[19e22]. Mortality rate.
Fortunately, majority of patients managed in the form of chest
physiotherapy, analgesia, antibiotics and by closed tube thor- 2.3.1. Independent variables
acostomy procedure. However, a few requiring thoracotomies Socio demographic factors (Age, sex), time of arrival, systolic
(7e20%). Tube thoracostomy is frequently used in thoracic trauma blood pressure on arrival, chronic medical illness, mechanism of
patients. It is required in case of pleural disruption caused by injury, types of chest injury, associated injury, treatment modal-
hemothorax, pneumothorax or hemopneumothorax. In life- ities, severity of chest injury, the need for ICU admission, the need

Table: 1
Basic characteristics of study participant from June 2016 to June 30, 2020 G.C.

Status Category N (%) Outcomes X2

Death Recovered

Sex Male 321 (76.6) 84 237 .897

Female 98 (23.4) 25 73
Age (years) <20 63 (15) 10 53 . .002
21e35 185 (44.2) 38 147
36e50 95 (22.7) 33 62
>50 76 (18.1) 28 48
Blood Pressure (mmHg) <90 55 (12.4) 23 29 .001

90 367 (87.6) 86 281
GCS on admission 3e8 36 (8.6) 23 13 .000
9e12 32 (7.6) 15 17
13e15 351 (83.8) 71 280
Presence of chronic comorbidity Yes 112 (26.7) 37 75 .048
No 307 (73.3) 72 235
Length of Hospital stay (days) Mean ± Sd ¼ 9.40 ± 3.879

2
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

patients were males. Males to females’ ratio were 3:1. The majority
192 (45.8%) of chest trauma patients admitted to health care fa-
cilities within 2e6 h after injury occurred while 174 (41.5%) of them
admitted after 6 h (Fig. 1). Upon hospital arrival 55 (12.4%) of pa-
tients had systolic blood pressure less than 90 mmHg. Thirty-six
(8.6%) of patients had Glasco comatose scale of 3e8 on admis-
sion. Nearly one-fourth (112, 26.7%) patients were with history of
underlying chronic comorbidities of which cardiovascular disease
were the commonest disease 50 (11.9%). The average length of
hospital stay was 9.40 ± 3.879 days (Table 1).

3.2. Pattern and mechanism of injury

Fig. 1. Time spent between injury and admission from June 2016 to June 30, 2020 G.C.

Violence was the most common mechanism of traumatic chest

injury followed by, road traffic collision which accounts for 220
for mechanical ventilation, presence of blood transfusion and
(52.5%) and 120 (28.6%) cases respectively. The majority 234 (55.8)
presence of complications.
of patients had blunt chest injury while 185 (44.2%) had pene-
trating chest trauma. The ratio of blunt trauma to penetrating
2.4. Data processing and analysis
trauma was 1.3:1. Nearly, three fourth (311, 74.2%) of the victims
were admitted with isolated chest injury whereas the rest of the
The collected data was checked manually for completeness.
victims had sustained thoracoabdominal injuries. The majority of
After cleaning and coding it was also entered into Epi-info-7 then
victims had unilateral injurie 357 (85.2%) whereas 14.8% of the
exported to Statistical Package for the Social Sciences (SPSS) version
patients had chest trauma involving both sides of the chest. During
20.0 windows for analysis. Chi-square test was used to test for
admission, among traumatic chest injured patients 291 (70.4%) had
significance of associations between the predictor and outcome
associated extra-thoracic injuries. The commonest were extrem-
variables in the categorical variables. Any variables that were sig-
ities (22.2%), head (21.7%) and abdominal injuries (18.1%) (Table 2).
nificant at P  0.2 in the bivariable analysis were candidate for entry
The most frequent type of chest injury was hemopneumothorax
into the multivariable analysis. The strength of the association
(116, 27.7%) followed by hemothorax (96, 22.9%) and rib fracture 72
presented by adjusted odds ratio and 95% Confidence interval. P-
(17.2%) (Table 3).
value less than 0.05 were considered as statistically significant.
Finally, data was presented by using numbers, frequencies, tables
and figures. 3.3. Management

3. Results As regards to the various treatment options for chest injuries, 76

(18.1%) were treated non-operatively. Chest tube was inserted in
3.1. Basic characteristics of chest trauma patient nearly two third of 271 (64.7%) of patients. Advanced procedures
such as laparotomy and thoracotomy were done for 14.3% and 2.9%
A total of 419 traumatized chest injury patient charts were of the chest injury patients respectively. Forty-six (11%) of patients
reviewed. The mean ± SD of patients' age were (36.17 ± 15.6) years. were admitted to ICU and thirty-six (7.9%) were need mechanical
The maximum number 185 (44.2%) of patients' age was between 21 ventilation. Blood transfusion had done in thirty-four (5.5%) of
and 35years. Nearly three-fourth 321 (76.6%) of chest trauma cases (Table 4).

Table 2
Injury Characteristics of study participants from June 2016 to June 30, 2020 G.C.

Status Category N (%) Out comes X2

Death Recovered

Cause of injury Violence 220 (52.5) 61 159 .572

RTA 120 (28.6) 27 93
Fall down 79 (18.9) 21 58
Severity of injury Unilateral 357 (85.2) 77 280 .000
Bilateral 62 (14.8) 32 230
Mechanism of injury Blunt 234 (55.8) 48 186 .004
Penetrating 185 (44.2) 61 124
Involved injured body region Pure chest 311 (74.2) 73 238 .044
Thoracoabdominal 108 (25.8) 36 72
Presence of associated extra thoracic injury Yes 295 (70.4) 98 197 .000
No 124 (29.6) 11 113
Associated head/neck injury Yes 91 (21.7) 44 47 .000
No 328 (78.3) 65 263
Associated abdominal injury Yes 76 (18.1) 20 56 .947
No 343 (81.9) 89 254
Associated extremities injury Yes 93 (22.2) 13 80 .003
No 326 (77.8) 96 230
Associated pelvic injury Yes 20 (3.8) 7 13 .34
No 399 (95.2) 102 297
Associated Spinal cord injury Yes 21 (5.0) 15 6 .000
No 398 (95) 94 304

3
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Table 3
Type of chest injuries presented from June 2016 to June 30, 2020 G.C

Types of injury Number of Patients Percentages Cumulative Percent

Hemothorax 96 22.9 22.9

Pneumothorax 69 16.5 39.4
Hemopneumothorax 116 27.7 67.1
Flail chest 13 3.1 70.2
Pulmonary contusion 13 3.1 73.3
Rib fracture 72 17.2 90.5
Chest wall wound 24 5.7 96.2
Diaphragmatic rupture 16 3.8 100.0

Table 4 and multicollinearity. In a multivariate analysis, the associated risk

Intervention given to chest injury patients from June 2016 to June 30, 2020 G.C factors of death identified as age above 50 years old, Time spent
Status Category N (%) Outcomes X2 between injury and admission to hospital >6hr, bilateral chest
Death Recovered
injury, penetrating chest injury, the presence of associate head/
neck, spinal cord injuries and need of mechanical ventilation, were
ICU admission Yes 46 (11) 28 18 .000
useful predictors of mortality in chest injured patients (Table 6).
No 373 (89) 81 292
Mechanical ventilation need Yes 36 (8.6) 29 7 .000 After controlling those significant factors related to outcome
No 383 (91.4) 80 303 (p < 0.05) (Table 6), death was nine times more likely happened in
Blood transfusion (units) Yes 23 (5.5) 8 15 .003 patients who were older than 50 years (AOR 9.32,95%CI 2.72e31.86,
No 396 (94.5) 97 299
p ¼ 0.000 (Table 6).
Non operative Intervention Yes 76 (18.1) 13 63 .702
No 343 (81.9) 76 210 Patients who spent >6 h before receiving health care following
Chest tube drainage Yes 271 (64.7) 64 207 .230 injury were seven times more likely to die from traumatic chest
No 148 (35.3) 45 103 injury than those arrived at health care facilities within the first 2 h
Thoracotomy intervention Yes 12 (2.9) 7 5 .010 of injury (AOR 7.17, 95% CI 1.76e29.21), p ¼ 0.006 (Table 6).
No 407 (97.1) 102 305
The presence of bilateral chest injury predicts the outcome of
Laparotomy Yes 60 (14.3) 22 38 .042
No 359 (85.7) 87 272 chest injury patients. A multivariate analysis showed that injury to
both side of chest were four times more likely to cause death than
unilateral chest injury (AOR 3.58,95% CI 1.53e8.38), p ¼ 0.003
(Table 6). Indeed, chest injury patients who had penetrating
Table 5 mechanism of injury were nearly four times risk of death than blunt
Complications developed by chest injury patients. (AOR 3.63 95% CI 1.65e7.98), p ¼ 001 (Table 6).
Status Category N (%) Outcomes X2 Moreover, the existence of associated injuries to the other re-
gion of the body determines the outcome of chest injury patients.
Death Recovered
Indeed, chest injury patients who had associated head and neck
Presence of complication Yes 148 (35.5) 59 89 .000 injury were four times more likely to die than their counterparts
No 271 (64.5) 50 221
(AOR 3.56, 95% CI 1.31e9.72). Also, patients who had associated
Pneumonia Yes 58 (13.8) 25 33 .001
No 361 (86.2) 84 277 spinal cord injury were five times more likely to die than their
wound sepsis Yes 38 (9.1) 20 18 .000 counterparts (AOR 4.8, 95% CI 1.13e20.47) (Table 6).
No 381 (90.9) 89 292 Traumatic chest injury Patient who needs artificial ventilation
Atelectasis Yes 53 (12.6) 14 39 .943
via mechanical ventilators were eleven times more likely die than
No 366 (87.4) 95 271
those who didn't need mechanical ventilation (AOR 11.18, 95% CI
2.11e59.23) (Table 6).

3.4. Complications
4. Discussion
The majority 271 (64.5%) of chest injury patients were treated
without developing complications while nearly, one third of 148 A retrospective study done in Syria showed; Mortality occurred
(35.5%) had complications in hospital. These complications in 1.8% of patients. The first etiology of chest injuries was violence
included pneumonia 58 (13.8%), atelectasis 53 (12.6%) and wound (41%) then by road traffic accident (33%). The most frequent types of
sepsis 38 (9.1%) (Table 5). chest injury were; pneumothorax (51%), hemothorax (38%), rib
fractures (34%), and lung contusion (15%). Besides, extra-thoracic
3.5. Mortality injuries occurred in 35% of patients [26].
According to the study conducted in United Arab Emirates on
The overall mortality in patients with traumatic chest injury was chest trauma patients the mortality rate was 7.2%. The primary
109 (26.0%). The result demonstrates the correlation between old cause of injury was road traffic events (66%) followed by falls
age, time of presentation to the hospital, penetrating injury, bilat- (23.4%). From the total of study subjects about (36.5%) had isolated
eral chest injury, associated extra-thoracic injuries to (spinal cord chest injury, but the remaining had associated head injury (27.4%)
injury and head/neck) and need for mechanical ventilation. and extremities (50%). mortality was associated with severe head
injuries (p < 0.0001) and low systolic blood pressure on arrival
3.6. Predictors of mortality among chest injury patients (p ¼ 0.027)[27].
In this study 419 eligible chest injured patients were admitted to
The logistic regression results for mortality risk factors are listed the hospital during the study period and the mortality rate has
on Table 6. There were no violations of assumptions of normality been found as 26.0% (95% CI: 21.7.0e30.5). This figure is comparable
4
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

Table 6
Multivariate Logistic Regression Analyses for Factors associated with mortality after chest trauma.

Variables N (%) Odds ratio (95% CI)

COR (95% CI) AOR (95% CI)

Age <20 63 (15) 1 1

21e35 185 (44.2) 1.37 (0.64e2.94) 1.44 (0.52e4.02)
36e50 95 (22.7) 2.82 (1.27e6.26) 2.74 (0.90e8.39)
>50 76 (18.1) 3.09 (1.36e7.03) 9.32 (2.72e31.86)***
Time between injury and admission (hr.) <2 53 (12.7) 1 1
2e6 192 (45.8) 3.22 (1.10e9.47) 3.22 (0.75e13.73)
>6 174 (41.5) 7.31 (2.52e21.18) 7.17 (1.76e29.21)**
Severity of injury Unilateral 357 (85.2) 1 1
Bilateral 62 (14.8) 3.88 (2.22e6.78) 3.58 (1.53e838)**
Mechanism of injury Blunt 234 (55.8) 1 1
Penetrating 185 (44.2) 1.91 (1.23e2.96) 3.63 (1.65e7.98)***
Presence of associated extra thoracic injury Yes 295 (70.4) 5.11 (2.63e9.94) 4.80 (1.47e15.72)**
No 124 (29.6) 1 1
Associated head and neck injury Yes 91 (21.7) 3.79 (2.31e6.20) 3.56 (1.31e9.72)*
No 328 (78.3) 1 1
Associated Spinal cord injury Yes 21 (5.0) 8.09 (3.05e21.43) 4.80 (1.13e20.47)*
No 398 (95) 1 1
Mechanical ventilation need Yes 36 (8.6) 15.69 (6.63e37.13) 11.18 (2.11e59.23)**
No 383 (91.4) 1 1

Note: *p < 0.05, **p < 0.01, ***p < 0.001 AOR: Adjusted Odds Ratio; COR: Crude Odds Ratio.

to a result reported by Baru et al. 27.6%, Massaga F.A et al. 24.2% and associated with mortality among chest injury patients with (AOR
Sanjay Datey et al. 22.23% respectively [9,28,29]. But much higher 3.63 95% CI 1.65e7.98). This is in accordance with other studies
than studies reported by Al-Koudmani et al., and Al-Eassa EM et al. reported by Ali et al. [36].
and Khursheed SQ et al. [12,26,30] This discrepancy may be due to In our study unilateral chest injury occurs more commonly.
different care treatment standards. However, patients having bilateral chest trauma is significantly
Our study found that chest trauma predominantly affects male associated with a higher risk of mortality than unilateral chest
and young age. This finding is consistent with results reported by injury (AOR 3.58, 95% CI 1.53e8.38). Ekpe EE et al. reported similar
other studies[12,15,31,32]. The reason for this observation might be finding[15].
males and younger ages were engaging in high-risk activities more Regarding the type of chest injury, majority of the patients had
than elder and females. However, chest trauma to old age patients hemopneumothorax 116 (27.7%) whereas hemothorax and rib
has been found to be predictor factor for death. Indeed, Patients fracture were diagnosed in 96 (22.9%) and 72 (17.2%) cases
aged >50 years were nine times more likely die from chest injury respectively. This result was consistent with the study done in
than those aged below 20 years (AOR 9.32). Other recent studies in Addis Ababa reported as hemopneumothorax was commonest type
line with this finding[28,33]. of chest injury[37]. However, other studies from Ethiopia, Uganda
Our study found that most of patients were presented to health and India reported as rib fracture was the commonest types of chest
care facilities in the time period of 2e6 h of injury (45.8%) and after injury[12,31,38]. The disparity might be related with the difference
6 h (41.6%). Rajesh K. Jegoda et al. reported the average time spent in cause of injury. But this is not statistically significance amongst
between the event and admission was 11 h and 12 min[31]. the types of chest injuries on outcome analysis.
Furthermore, late presentations (>6hrs) to health care center were Our study found that 70.4% of patients had associated extra-
associated with mortality in this study (AOR 7.17, 95% CI thoracic injuries. This finding was nearly consistent with the
1.76e29.21). Similar to our result with AOR 4.6, 95% CI 1.19e18.00 result of the study conducted in Uganda 64.8% and Tanzania 61.3%.
showed patients that were arrived to the hospital later had higher Interestingly, injury other than spinal cord and head/neck injury
mortality rate than those who were arrived earlier[28]. The reason didn't significantly correlate with the mortality rate. Similar to
could be absence of systematized ambulance service with first re- others, our result showed that, spinal cords injury (P ¼ 0.034) and
sponders and a lack of trauma center in the country accounted for head/neck injury (p ¼ 0.013) statically associates with mortality
few numbers of patients were arrived within the early hours of [28]. In this study head injuries were 21.7% which was almost
injury. similar with the studies in Tanzania 21.8% and Sudan 19%[9,39].
In agreement with the other study we found that majority of In our study majority of the patients (81.9%) received surgical
victims were injured by violence followed by Road traffic accidents management, of whom 64.7% chest tube drainage, 14.3% explor-
(RTA) [4]. Assault were the leading cause of injuries and responsible atory laparotomy and 2.9% underwent thoracotomy. The remains
for 52.5% of all injuries. However, this figure is higher than study which were 18.1% of patients needed none operative intervention
reported by Al-Koudmani et al. 41%[26]. The reason to such high in the form of chest physiotherapy and analgesics. This finding is
figures might be due to increased assaults in this study area. comparable to Khursheed SQ et al. chest tube was done in 65%,
Blunt chest injuries were more common than penetrating chest thoracotomy 3.75%[12]. However, our result was low from study
injuries 55.8% vs 44.2%. This finding was in line with previous reported by Rajasekhar N. et al. chest tube was done in 75.35%,
studies from Uganda 57.7%, Nigeria 53%[11,32]. The result of this thoracotomy 5.56%. The difference may be presence of more
study is much lower than the study conducted in United Arab experienced thoracic surgeons[23].
Emirates 66%, another study Nigeria 69.7% and Tanzania 75.6% In this study 8.6% of patients require supportive mechanical
[9,30,34]. This difference may be due to the difference in causes of ventilation among chest trauma patients. This is much lower than
injury. Even though, penetrating chest trauma is less common than the study conducted India,18.68%.The disparity may be the severity
blunt trauma, it was more deadly[35]. Penetrating chest injury of traumatic chest injury[23]. The need for mechanical ventilation

5
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

was also among the factors associated with increased mortality in Author contribution
chest trauma patients, p ¼ 0.01, which is agreed by a study of
Refaely Yael et al. p ¼ 0.01[40]. Authors' contributions: This work was carried out in collabo-
Similar to others our study found that pneumonia was the ration among all authors. AE contributed to the conception and
leading cause of complications. In contrast to this findings from design of the study, acquired; analyzed and interpreted the data
Ugandan study the incidence was low[11]. Even though we have no drafted and revised the manuscript. SY, AH and HA participated in
specific data to clarify the reasons why those patients not correlate reviewing the design and methods of data collection, interpretation
with high mortality. On the other hand, study from India showed and preparation of the manuscript. All authors participate in
atelectasis was the most common morbidity. Surprisingly, in this preparation and critical review of the manuscripts. In addition, all
study the presence of complications was not associated with authors read and approved the manuscript.
mortality. The reason might be due to aggressive initial treatment
of those specific morbidity and standard of care provided. Registration of research studies

5. Conclusion and recommendations researchregistry7105.

The mortality rate in traumatic chest injury was high. Late Guarantor
presentation beyond 6hr, age >50-year, penetrating injury, Bilateral
chest injury, associated extra thoracic injury and need of mechan- Salh Yalew Mustofa, Abubeker Eshetu Yimam, Amare H/kiros
ical ventilation were identified as possible risk factors for mortality Gebregzi, Habtu Adane Aytolign.
in traumatic chest injury patients.
We recommend development of standard care practices and the
Declaration of competing interest
trauma team needs a better preparation to provide effective
treatment strategies when encountering traumatic chest injured
The author declares there is no conflict of interest.
patients. The mortality varies by the pattern of injury with the
highest among victims of violence. This suggests the need for
awareness creations to society on their health seeking behavior and Appendix A. Supplementary data
conflict resolution programs. Establishment of organized pre-
hospital services and provision of a sustainable ambulance ser- Supplementary data related to this article can be found at
vice with trained staff is recommended. https://doi.org/10.1016/j.ijso.2021.100420.

References
Acronyms and abbreviations
[1] Organization WH. Violence, injuries and disability: biennial report 2010-2011.
AOR: Adjusted Odd Ratio, OR: Cured Odd Ratio, G.C: Gregorian 2012.
calendar, GCS: Glasgow comatose score, ICU: Intensive Care Unit, [2] Whizar-Lugo V, Sauceda-Gastelum A, Herna ndez-Armas A, Garzo n-Garnica F,
Granados-Go  mez M. Chest trauma: an overview. J Anesth Crit Care Open
LOS: Length Of stay, RTA: Road Traffic Accident, SD: Standard De- Access 2015;3(1):00082.
viation, SPSS: Statistical Package for the Social Sciences. [3] Datey S, Tayagi A, Charles N, Lazarus A, Gadodia M, Gupta M. Study OF clinical
profile And outcome OF 216 victims OF chest trauma IN tertiary care centre OF
CENTRAL India. J Evol Med Dent Sci 2015;4:15843e7.
Limitations [4] Zeleke TAABM, Melak GATMF. Magnitude and patterns of injuries among
patients in, northwest Ethiopia: an institutional-based study. 2017.
[5] Abafita BJ, Abate SM, Kasim HM, Basu BJEJoHS. Pattern and outcomes of in-
Since it was a retrospective study we were not directly observes
juries among trauma patients in Gedeo Zone, Dilla, South Ethiopia: a 5 Years
patients’ condition including their vital sign and treatment inter- retrospective analysis. Ethiop J Health Sci 2020;30(5).
vention. Though we were only focused on what was documented [6] Gebru Addis A, Mosadeghrad Ali M, Sari Ali A, Tafesse Tadesse B, Kahsay
Woldegebriel G. Prevalence, pattern, magnitude and associated factors of
on patients chart. As much as possible we were trying to avoided
trauma in the Emergency Department at Health Institutes in Ethiopia: a
incomplete, unclear and ambiguous documents. Even if mortality is systematic review. Hum Antibodies 2019;27:1e10.
an indicator of trauma burden, many more survivors are left with [7] Tadesse B, Tekilu S, Nega B, Seyoum NJE, CAJo Surgery. Pattern of injury and
permanent disability. We did not have access to long-term out- associated variables as seen in the emergency department at Tikur Anbessa
specialized referral hospital, Addis Ababa, Ethiopia. Ethiop J Health Sci
comes to show the full picture of the trauma burden. Further 2014;19(1):73e82.
studies may require for looking long-term outcomes of chest [8] Bashah DT, Dachew BA, BTJBem Tiruneh. Prevalence of injury and associated
trauma patients. factors among patients visiting the Emergency Departments of Amhara
Regional State Referral Hospitals, Ethiopia: a cross-sectional study. BMC
Emerg Med 2015;15(1):20.
Sources of funding [9] Massaga FA, Mchembe M. Cajo surgery The pattern and management of chest
trauma at Muhimbili National Hospital. Dar es Salaam 2010;15(1):124e9.
[10] Kumar A, Garg RK. Assessment of cases of traumatic chest injuries in hospi-
Self-sponsorship and funded. talized patients. J Adv Med Dent Sci Res 2017;5(3).
[11] Mwesigwa M, Bitariho D, Twesigye DJE, CAJo Surgery. Patterns and short term
outcomes of chest injuries at Mbarara regional referral hospital in Uganda.
Ethical approval East and Central Afr J Surg 2016;21(3):28e35.
[12] Khursheed SQ, Ashraf W, Aajisj Rather. Clinical profile and outcome of chest
trauma: a four year retrospective analysis at a tertiary care centre. Int Surg J
Ethical approval was obtained from ethical committee board of 2019;6(7):2519e24.
university of Gondar specialized Hospital. [13] Bouzat P, Raux M, David JS, Tazarourte K, Galinski M, Desmettre T, et al. Chest
But reference number is not necessary it is already approved. trauma: first 48hours management. Anaesthesia, Crit Care Pain Med
2017;36(2):135e45.
[14] RMJZJoMS Haweizy. Pattern and outcome of penetrating chest injuries at the
Consent Emergency Management Center in Erbil City. Zanco J Med Sci 2019;23(3):
429e38.
[15] Ekpe EE, CJNJoS Eyo. Determinants of mortality in chest trauma patients. J Adv
Not applicable since it is retrospective study. Med Med Res 2014;20(1):30e4.

6
A.E. Yimam, S.Y. Mustofa, A.H.–g.–> Gebregzi et al. International Journal of Surgery Open 37 (2021) 100420

[16] Dennis BM, Bellister SA, Guillamondegui OD. Thoracic trauma. Surg Clin N Am [28] Baru A, Weldegiorgis E, Zewdu T, HJCjot Hussien. Characteristics and outcome
2017;97(5):1047e64. of traumatic chest injury patients visited a specialized hospital in Addis
[17] Tobey N, Lopez RA, Waseem M. EMS Chest Injury. StatPearls. Treasure Island Ababa, Ethiopia: A one-year retrospective study. 2020.
(FL). StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020. [29] Datey S, Tayagi A, Charles N, Lazarus A, Gadodia M, Gupta MJJoEoM, et al.
[18] Lema MK, Chalya PL, Mabula JB, Mahalu W. Pattern and outcome of chest Study of clinical profile and outcome of 216 victims of chest trauma in tertiary
injuries at Bugando medical centre in Northwestern Tanzania. J Cardiothorac care centre of central India. J Evol Med Dent Sci 2015;4(93):15843e8.
Surg 2011;6(1):7. [30] AlEassa EM, Al-Marashda MJ, Elsherif A, Eid HO, Abu-Zidan FMJJocS. Factors
[19] Tesfay K, Assefa M, Zenebe D, Gebremicael M, Kebede G, Gebrekirstos H. Road affecting mortality of hospitalized chest trauma patients in United Arab
traffic injured patients with severe GCS and organ injury had a poor prog- Emirates. J Cardiothor Surg 2013;8(1):57.
nosis: a retrospective cohort study. BMC Publ Health 2019;19(1):749. [31] Rkjisj Jegoda. Profile of chest injuries in a tertiary care centre. Int Surg J
[20] Seid M, Azazh A, Enquselassie F, Yisma E. Injury characteristics and outcome 2020;7(3):714e6.
of road traffic accident among victims at Adult Emergency Department of [32] Okugbo S, Okoro E, Irhibogbe P. Chest trauma in a regional tRAUMA centRE.
Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia: a prospective J West Afr Coll Surg 2012;2(2):91e101.
hospital based study. BMC Emerg Med 2015;15(1):10. [33] Okonta KE, Eojisj Ocheli. Chest trauma in the older people: epidemiological
[21] Getachew S, Ali E, Tayler-Smith K, Hedt-Gauthier B, Silkondez W, Abebe D, profile and treatment outcome. Int Surg J 2018;5(8):2697e700.
et al. The burden of road traffic injuries in an emergency department in Addis [34] Griwan M, Kumar S, Pal N. To study the etiology, pattern and short term
Ababa, Ethiopia. Publ Health Act 2016;6(2):66e71. outcome of chest injuries as prospective study. Int Surg J 2016;4(3):6e11.
[22] Hunchak C, Teklu S, Meshkat N, Meaney C, LPJBrn Ritchie. Patterns and pre- [35] Jain A, Sekusky AL, Burns B. Penetrating Chest Trauma. StatPearls. Treasure
dictors of early mortality among emergency department patients in Addis Island (FL). StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.;
Ababa, Ethiopia. BMC Res Notes 2015;8(1):605. 2020.
[23] Narayanan R, Kumar S, Gupta A, Bansal VK, Sagar S, Singhal M, et al. An [36] Ali N, Gali B. Pattern and management of chest injuries in Maiduguri. 2004.
analysis of presentation, pattern and outcome of chest trauma patients at an Nigeria.
urban level 1. Trauma Center 2018;80(1):36e41. [37] Adem A, Ilagoa R, Mekonen EJE, CAJo Surgery. Chest injuries in Tikur Anbessa
[24] Feenstra TM, Dickhoff C, Deunk J. Systematic review and meta-analysis of tube hospital. Addis Ababa: a three year experience 2001;6(1).
thoracostomy following traumatic chest injury; suction versus water seal. Eur [38] AJAoM Baram, Surgery. Bilateral thoracic trauma; presentation and manage-
J Trauma Emerg Surg 2018;44(6):819e27. official publication of the European ment. Case Ser 2019;43:25e8.
Trauma Society. [39] Yousif Mohammed Saeed PAAH, M Ismail Dr Omer, Abdelrazag Dr. Pattern
[25] Bertoglio P, Guerrera F, Viti A, Terzi AC, Ruffini E, Lyberis P, et al. Chest drain and Management Outcome of Chest Injuries in Omdurman Teaching Hospital.
and thoracotomy for chest trauma. J Thorac Dis 2019;11(Suppl 2):S186. s91. 2015.
[26] Al-Koudmani I, Darwish B, Al-Kateb K, YJJocs Taifour. Chest trauma experience [40] Refaely Y, Koyfman L, Friger M, Ruderman L, Saleh MA, Sahar G, et al. Clinical
over eleven-year period at al-mouassat university teaching hospital- outcome of urgent thoracotomy in patients with penetrating and blunt chest
Damascus: a retrospective review of 888 cases. J Cardiothor Surg 2012;7(1): trauma: a retrospective survey. Thorac Cardiovasc Surg 2018;66(8):686e92.
35. [41] Agha R, Abdall-Razak A, Crossley E, Dowlut N, Iosifidis C, Mathew G, for the
[27] AlEassa EM, Al-Marashda MJ, Elsherif A, Eid HO, Abu-Zidan FM. Factors STROCSS Group. The STROCSS 2019 Guideline: strengthening the reporting of
affecting mortality of hospitalized chest trauma patients in United Arab cohort studies in surgery. Int J Surg 2019;72:156e65.
Emirates. J Cardiothorac Surg 2013;8(1):57.