SURGICAL ASPECTS OF ACCIDENTS IN CHILDHOOD 63 this injustice, but the older .age group frequently develop a metabolic disturbance which will tip the balance the wrong way as regards recovery. During the first twenty-four hours at least one pint of glucose and water is necessary and this should be increased so that the total intake is up to two pints during the second twenty-four hours. After the third day protein in some form must be introduced into the diet as otherwise the patient will commence to lose weight. At the present time we are using one of the proprietary high protein prepara- tions (Complan) and milk, given by a gastric drip. Electrolytes should be estimated frequently, paying particular atten- tion to the serum potassium. A reduction of potassium to a figure between eight and fourteen mgs. can occur withia twenty-four hours. The bronchial secretion should be frequently examined and this will be a guide to the use of antibiotics. At the present time I initially use penicillin (one million units 4- hourly) and sulphanethazine (one gramme 6-hourly). The patient's position should be frequently changed, and he should be turned from side to side every two hours. Physiotherapy should be practised twice daily if possible to help full expansion of the lung bases. Before applying suction (which should be done frequently) it is useful to place the patient in an extreme head down position for about ten minutes. The application of this treatment has lowered the morta]ity rate in this group of severe head injuries. Most modern hospitals are in a position to undertake this task, and I am gl'ad to say that I have seen quite a few cases of severe cerebral trauma which have been dealt with successfully in county hospitals by the application of these methods. Judging from the increasing number of road accidents, none of us will be left short of material in this sphere. The measures that I have outlined will allow the vital centres to resume control in a certain number of cases, ~nd frequently will result in the useful recovery of a case of severe head injury. References. Alexander, G. L., Journal 1 .M.A . , September 1955. Johnson, R. T. (1957). Modern Trends in Neurology, 2nd series, 274. Lanigan, J. P., Journal I .M .A . , September 1955. McCon.nell, A. A., Journal I .M .A . , September 1955. Metciver, Lassman, Thomson & McLeod (Lancet, p. 544, 13/9/1958). CHEST INJURIES By KEITH SHAW, M.D., F.R.C.S.I. Royal City of Dublin Hospital T HE increasing pace of modern life and, in particular, the speed and fragil ity of the modern motor-car, are bringing us into contact with a type of violent in jury rarely seen until recent years. The occupant of a crashed car is likely to sustain a fractured skull, a stove- 64 IR ISH JOURNAL OF MEDICAL SC IENCE in chest, and two broken legs. I would like, therefore, at the beginning of this talk on chest injuries to stress that it is the patient that is injured, and the patient that must be treated. Tho assessment of the extent of the damage, in a severely injured patient can be formidable and may have to be deferred for the more urgent business of live-saving first-Md. In order to render first-aid in the right order it is necessary to decide what are the threats to life. The immediate threats are shock, haemorrhage and respiratory depression, and it is re:~piratory depre.~- sion which is the particular and often decisive factor in injuries of the chest. Respiration can be depressed in various ways: (1) by pain, (2) by instability of the chest wall, as in stove-in chest, (3) by fluid, and/or air in the pleural cavity, (4) by injury to the lungs or air passages, (5) by blockage of bronchi and atelectasis, (6) by rupture of the diaphragm and herniation of abdominal viscera into the chest, (7) by coma. The maintenance of adequate respiration is, of course, vital, not only to prevent fatal anoxia, but also to prevent the accumulation of carbon dioxide, which will lead to respiratory acidosis, coma, and death. In these circumstances the treatment of shock by morphia or other respira- tory depressants must be cautious, at least until facilities are available for assisted or controlled respiration. Severe chest injuries can be conveniently considered from two aspects : (1) injury to the parietes, including bony cage and diaphragm; (2) injury to the thoracic contents, including lungs, heart, trachea, oesophagus, great vessels and thoracic duct. There is no correlation between these groups, unless perhaps it be an inverse one, e.g., a boy of 2½ years, run over by the wheel of a milk van, exhibited dyspnoea and vomiting, with signs of fluid in the left chest. X-ray showed a large homogeneous opacity in the left chest. Aspiration of the pleura produced stomach contents, and operation revealed a linear rent in the diaphragm with herniation of stomach and colon into the chest. Now this patient had no mark or bruise on the chest wall, and no fractured ribs. Rupture of the diaphragm was due to elastic recoil. Conversely, a severe crush injury with many fractured ribs and a paradoxical chest wall may cause death from respiratory insufficiency without much evidence of visceral damage. In fact, really severe injury to the lungs or heart is rather exceptional in civil practice, at least in those eases that survive long enough to receive hospital treatment. This is true at any rate in this country, where knife and gunshot wounds arc rarely seen. What then are the factors which affect the gravity of a chest injury and which therefore must be assessed in every ease? (1) The degree of instability of the chest wall Fractures of many ribs can be present without instability, but where many ribs are fractured in more than one place, or bilaterally, portion of the thoracic cage becomes unstable, and this can easily be diagnosed by the presence of paradoxical movement, or by gentle manipulation. This instability reduces ventilation, not only by virtue of disordered chest expansion, but also by the paradoxical movement of the unstable area, producing a displacement of expired air into normally expanding SURGICAL ASPECTS OF ACCIDENTS IN CHILDHOOD 65 lung. A vicious circle is established because increasing anoxia produces increased respiratory effort, and therefore increased paradoxical flapping. (2) The presence of blood, air, or both in pleural cavity It is a cardinal principle of thoracic surgery that the pleural cavity should at all times remain a potential space, that is, it should be obliterated. Now that artificial pneumothorax has been abandoned as a therapeutic measure, this principle is also accepted by most physicians. Lung capacity is, of course, diminished in direct proportion to the amount of air or fluid in the pleura. A very large quantity of blood can be comfortably accommodated in one pleural cavity, with surprisingly little clinical or x-ray evidence, and failure to appreciate this may delay vitally necessary blood transfusion. Air in the pleura, in the absence of an open pneumothorax or visceral herniation, must indicate pulmonary or airway laceration or oesophageal rupture. However, a very trivial pulmonary tear can produce a rapidly progres- sive tension pneumothorax, and/or surgical emphysema. (3) Visceral injury Some degree of pulmonary injury, in the form of contusion or laceration, is common, and can be inferred from haemopneumothorax and haemoptysis. Cardiac injury is less common, but probably much more frequent than is generally recognised. It usually takes the form of contusion, due, to direct compression of the sternum or anterior ribs and can produce a condition similar to acute coronary insufficiency, aggravating shock. It can be detected by the pattern of injury on the ECG. Blood in the pericardium ;nay produce tamponade. The oesophagus is rarely injured except by penetrating wounds, but the diaphragm can be ruptured by the recoil of a crushing injury, or by a fractured rib fragment. Indeed, a fractured rib can penetrate the abdomen and lacerate the bowel, thence returning on recoil to its normal position. (4) History of pr'e-existing p~dmonary disease Chronic bronchitis and emphysema are common diseases, and their presence will substantially increase the effects of any chest injury and make its management more difficult. It is my impression that an abnormal lung is a greater risk than a normal one in a relatively trivial chest injury. (5) Multiple injuries As has been stressed, the patient must be assessed as a whole as far as possible. Head injury makes the problem enormously more difficult, both in assessment and treatment. Coma may be cerebral or respiratory in origin, and differentiation may have to await the establishment of an ad~. uate respiratory exchange. Prolonged respiratory anoxia will aggravate the effects of what might otherwise be minor cerebral contusion and produce critical cerebral oedema. A chest radiogram is of the greatest importance in assessment, not 66 IR ISH JOURNAL OF ~IEDICAL SCIENCE only for the extent of bone injury, but to determine the presence of air or fluid in the pleura, or atelectasis or haematoma in the lung, or pericardial effusion. It is also vital at this stage for a base line so that progress of treatment can be gauged. Management Before considering the severe injury, a word is necessary about the management of simple rib fractures. There is a dilemma here, in that immobilisation, either therapeutically by strapping, or by splinting due to pain, may lead to sputum retention, atelectasis and pneumonia. Strapping of the chest for fractured ribs is usually done so inefficiently as to have no effect, and this is probably fortunate. It is better to treat the pain by analgesics or by injection of long-acting local anaesthetic at the fracture site or sites. The most urgent problem in the patient with severe chest injuries is the maintenance of adequate ventilation, and it is probably lack of ventilation which kills these patients before they reach hospital. There are two simple methods of ventilation which should be available in every ambulance : (1) Mouth to mouth ventilation. (2) A respirator such as the Stevenson Minuteman resuscitator. I would like at this stage to remind you of the very complex physio- logical effects of acute ventilatory insufficiency: (a) Anoxia : This is the most obvious and best understood effect. The normal physiological response to anoxia, increased respiratory effort, may be suppressed by shock, and cyanosis may be masked by haemorrhage and shock, both of which will enhance the tissue anoxia. (b) Respiratory acidosis due to C02 retention : This is a more subtle and probably more lethal effect of underventilation. Its symptoms arc sweating, flushing, rising blood pressure, confusion, coma, all leading to respiratory failure and death. All of these signs can be masked or overlooked in a shocked patient. For instance, a normal blood pressure can be maintained by the balance of haemorrhage and C02 retention. I have seen a patient after pneumonectomy passing into coma with hypoventilation and a normal blood pressure of 120/80. Intubation and hyperventilation produced a blood pressure fall to 70/0 and the patient woke up. Rapid transfusion of two pints of blood restored the blood pressure. Here is a typical case of haemorrhage and hypoventi]a- tion balancing the blood pressure, and this is a highly dangerous situa- tion producing rapid death if not vigorously corrected. (c) Diminished cardiac output : The return of blood to the right atrium depends to a significant extent on the periodic negative intra- thoracic pressure during normal respiration. This mechanism is impaired with hypoventi]ation and particularly with a flail chest, or open or closed pneumothorax. This impaired cardiac return aggravates the hypotensive effect of shock and haemorrhage. Its practical importance is that it may be aggravated by over-enthusiastic positive pressure ventilation. Having transported the patient, alive, to hospital, the priority of SURGICAL ASPECTS OF ACCIDENTS IN CHILDHOOD 67 treatment will depend on preliminary assessment, but I have no doubt that the most important step is establishment and maintenance of adequate ventilation, if necessary by general anaesthetic and controlled respiration. As already mentioned, a portable chest x-ray is of great help to confirm or assist clinical assessment. Bronchoseopy may have to be done to make sure that the airway is clear and free from injury. The pleural cavity must be obliterated. Pneumothorax is treated by an indwelling catheter connected to underwater drainage, and haemo- thorax by early and complete aspiration, repeated if necessary. " S tove- i~ Chest " This may involve a relatively small area of chest wall, as in the " steering wheel " injury, or the whole chest wall may be unstable with widespread bilateral rib fractures, as in fore and aft crush injuries. The local treatment will depend on circumstances, but in principle the most severe injuries can be managed by controlled ventilation through an endotraeheal tube, ,either manually or by means of a respirator. It is preferable to use a respirator which incorporates a negative phase, and it may be necessary to use quite high pressure in the positive phase ill order to maintain adequate gas exchange. It should also be stressed that the development of adequate ventilation and its consequent control of CO., build-up may produce hypotension and circulatory failure unless supportive measures, i.e., transfusion, and if necessary noradren- aline, are provided simultaneously. The tendency to circulatory failure may be aggravated if a high positive~ pressure is needed, and particu- larly if a negative phase respirator is not available. Paradoxical movement of a loealised stove-in injury can be adequately controlled by a firm pad which holds the unstable area in its depressed state. This has the slight disadvantage of minor permanent deformity, but may be life-saving. Larger defects may be controlled by simple devices, such as towel clips or pins through sternum or costal cartilages, and attached to weights or splints. In the severely dis- organised chest cage ,any form of splinting is secondary to endotraeheal control of respira~fion. There is seldom any indication or opportunity for open repair and fixation of these injuries. I f there is any doubt whatever of the patient's ability to maintain adequate respiration forthwith, traeheostomy should be performed. It is a mistake to continue the use of an endotracheal tube for more than twelve hours or so, because of the danger of laryngeal or tracheal necrosis. Tracheostomy using a cuffed rubber tube (if necessary a cut- down cuffed Magill tube) has the following advantages: (1) Assisted or controlled ventilation can be continued indefinitely. (2) Traeheo-bronchial secretions can easily be aspirated as required. ~3) The dead-air space between mouth and trachea is eliminated. This amounts to about 150 e.e. or about 20 per cent. of tidal volume. (4) Metabolism, and therefore oxygen requirements, is reduced, by elimination of restlessness and forced respiratory movement. 68 IR ISH JOURNAL O~ ~ MEDICAI . SC IENCE The improvement in these cases by tracheostomy can be immediate and spectacular. There is no longer any objection to sedation, so the patient can be made comfortable, and it is usually possible to dis- continue assisted respiration within a short period. Forced respiratory effort, which aggravates harmful paradoxical movement, is eliminated, and replaced by quite normal diaphragmatic movement with little or no paradox. This situation having been achieved, it is then possible to assess the patient's other injuries, if any. Continuing coma or confusion, in the presence of adequate gas exchange, may be due to cerebral damage or intracranial haemorrhage. The nursing and management of these cases requires constant vigilance, with particular regard to: (1) Keeping the pleural cavities free of air and blood. (2) Keeping the airway clear and preventing atelectasis. (3) Treatment of the pulmonary infection which frequently super- venes. Daily chest x-ray films should be taken for several days. Surgical Emphysema : This can be an alarming complication, the patient blowing up almost visibly. It is said that incisions should be made to release the air, but in spite of several cases with very severe emphysema, I have never found such incisions necessary. I agree, how- ever, that they might occasionally become necessary. The emphysema is, of course, aggravated by coughing, and tracheostomy not only provides a vent for air escape, but also obviates the necessity for frequent coughing. In recent discussions on the management of multiple injuries, with particular reference to road casualties, the need for specialist units has been stressed. Much thought has been given to the disposal of casual- ties with special problems, such as head and chest injuries. The gener- ally accepted view is, I think, that severe injuries are best treated in an accident unit, which should have freely available the benefit of specialist advice on any particular problem. In other words, the specialist should come to the patient, rather than viee versa. Such an accident unit would usually evolve within the framework of an orthopaedic depart- ment. Where definitive specialist treatment is required, the patient would subsequently be transferred to the appropriate unit, be it neuro- surgical, thoracic, genito-urinary, etc. The measures I have briefly discussed are on the whole simple, and call be initiated in any general surgical ,mit. The main problem is the necessity for continuous and unremitting vigilance, and this is a great strain on personnel.