THE CRUSHED - Thorax · THE CRUSHED CHEST paradox was unchecked and anoxia and carbon dioxide retention developed. A Bennett's respirator, using 100% oxygen and maximal inspiratory

Thorax (1961), 16, 3.

THE CRUSHED CHESTBY

HARRY M. WINDSOR AND BRIAN DWYERFrom St. Vincent's Hospital, Sydney

The primary object of this paper is to considerthe management of the badly crushed chest.At St. Vincent's Hospital, Sydney, about 20

patients with moderate to severe chest injuries areadmitted each year. Our original analysis of themortality and morbidity of 200 such cases in thepast eight years led us to believe that the methodsof complete control to be outlined in this papercould be used with advantage about three times inevery 40 cases, and in the past two years we usedthem on five occasions. Partial control is nowbeing used more and more frequently in caseswith injuries causing less severe paradox. Thedecision as to when completely to controlrespiration is difficult. In general it is carried outwhen paradox is so severe that it cannot becontrolled by simple means. This is illustrated inCases 1 and 2 of the following case reports.

CASE REPORTSCASE 1.-S. de K. (57/2490), a powerfully built

man of 42 years, was involved in a car accidenton November 16, 1957. He was seen by one ofus (H. W.) the next day. He had what could onlybe described as a "wobbly" chest. Many ribson both sides were fractured, some in two places.He had a small haemothorax, but no pneumo-thorax, and no significant injury elsewhere.Paradoxical respiration was severe and bilateral.He was extremely dyspnoeic. The injury was notin itself fatal, but the paradox was uncontrollableby simple means. Unfortunately, he was in theSnowy Mountains, 350 miles from Sydney, andhe was considered too ill to move at the time.This proved to be wrong, for, when two days laterhe was still alive and the decision to move him wasmade, he survived a two-hour bumpy trip in asmall plane.He was admitted to St. Vincent's Hospital at

3 p.m. on November 19. The inevitable hadhappened. The lungs were wet and opaque, andparadox was extreme.

Respiratory paralysis was at once induced andcontrolled respiration through a tracheostomy wasbegun. It was too late, because adequate ventila-tion could not be achieved on account of

widespread consolidation. The patient died thenext day.Necropsy revealed little other than the

comminuted rib fractures (fractures of 24 ribs)with a number of floating segments. Death wasdue solely to the results of paradoxical respiration.A critical inspection of the many scattered frac-tures demonstrated how fruitless any endeavour tocontrol the paradox by mechanical fixation wouldhave been.

This, then, is the type of case we see about threetimes in every 40 cases of moderate to severe chestinjury. It illustrates what we mean by severe anddangerous paradox.CASE 2.-In this case the injuries were more

extensive and serious than in Case 1. It is reported indetail in order to elaborate the method of controlof the paradox and to emphasize the application ofmodem thoracic surgical and anaesthetic principlesto severe chest injuries.An American, D. McN. (58/1939), aged 44, was

involved in a head-on collision at 12.5 a.m. onOctober 19, 1958. He received the full impact of thesteering column in the chest. He was admitted toManly Hospital under the care of Mr. MalcolmStanley and was first seen by one of us (H. W.) 14hours after the accident.At that time he was lying supine. He was semi-

conscious, cyanosed, and extremely dyspnoeic. Hehad gross, generalized, surgical emphysema withviolent, piston-like, paradoxical movement of theright upper anterior chest and sternal regions. Controlof the paradox had been attempted by the use of ahook attached to an overhead frame and inserted intoan upper right anterior rib. Radiographs of the chestshowed a right haemopneumothorax which had beentreated by a needle in the right pleural cavity.Bronchial obstruction due to secretions was marked.An abdominal injury was suspected, but a satisfactoryexamination was impossible at this time due to thepatient's dyspnoea, paradox, and confused mentalstate. He also had a compound fracture of the shaftof the right femur and a comminuted fracture of theright femoral trochanter. The tongue had received alarge ragged laceration, and most of the front teethhad been knocked out. The pulse rate was 100 perminute and the respirations 32 per minute. Morphia,96 mg., pethidine, 50 mg., pethilorfan, 100 mg., andparaldehyde, 10 ml., had been given in an effort tocontrol pain and restlessness.

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HARRY M. WINDSOR and BRIAN DWYER

It appeared to be absolutely necessary to controlthe paradoxical respiration and seemed to be possibleonly by abolishing the patient's spontaneous respira-tion with a muscle relaxant and instituting intermittentpositive pressure respiration. To do this, it was con-sidered essential to transfer the patient, even at greatrisk, to a thoracic surgical unit. He was admitted toSt. Vincent's Hospital at 4.15 p.m. on October 19.He was then cyanosed and restless, with frighteningparadox and gross bronchial obstruction fromsecretions.The management was as follows:Bronchoscopy.-This was done without anaesthesia,

and almost proved fatal. The trachea and bronchiwere full of blood and solid particles of vomit. Thedistal light on the bronchoscope rapidly becameoccluded, blood collected again, and the suckers soonblocked. The patient became deeply cyanosed andpulseless.

Intubation with a Cuffed Endotracheal Tube.-Thiswas done the moment it became obvious that persistingwith the bronchoscopy would be fatal. This resultedin more satisfactory ventilation, and further removalof intrabronchial blood was possible.

Tracheostomy and Insertion of Short Cuffed Endo-tracheal Tube.-A large tracheostomy was made andmore blood and vomit were removed.

Full Curarization and Controlled Respiration.-Immediately these steps were completed paradox was

controlled, but difficulty in maintaining adequateventilation was noted because of (1) increasedresistance to inflation, which a radiograph in thetheatre showed to be due to a large right haemo-pneumothorax (the original decompressing needlehaving blocked). This was decompressed by a largeintercostal catheter which drained 20 oz. of blood.The catheter was then connected to a suction pumpand the lung re-expanded. There was no continuousair leak from this pleural cavity. (2) An enormous

increase in the surgical emphysema developed, andwhen small incisions were made beneath the claviclesair hissed out with each squeeze of the bag. It alsoescaped freely around the tracheostomy so that usinga " closed circuit " flow rates up to 10 litres per minutewere required to maintain ventilation. Such a leakcould only come from a major air passage.

Operation.-At 9.15 p.m. a transverse incision was

made at the level of the third rib. The moment thesubcutaneous tissues were incised, gusts of air obtrudedwith every squeeze of the bag. The anatomy of thebony injury could now be seen. There was a com-

minuted fracture of the manubriosternal junction, theends being 2 in. apart; there were comminutedfractures of the anterior ends of the upper right ribs;and the right sterno-clavicular joint was completelydisrupted, leaving a gap of 2 in. The manubrium was

attached to the left clavicle. The mediastinum laybare.A rib spreader was inserted. It was at once

apparent that the air was issuing from deep in the

mediastinum via a dirty discoloured tract. Stomachcontents, including a few shreds of onion, were presentin the mediastinum. At this stage it was almostimpossible to keep the lungs inflated because of thetarge air leak, and further blood accumulated in thetracheobronchial tree due to the blood from inflamedmediastinal tissues pouring through the air leak. Alarge pack was placed in the mediastinum, and thisresulted in improved anaesthetic conditions. Thenext difficulty was finding the hole. The leftinnominate vein was stretched taut across the media-stinum and interfered with exposure, so it was at onceligated and divided. The innominate artery andaortic arch could then be retracted to the left whenthe site of the air leak became apparent. There wasa tear I in. long in the trachea situated at thejunction of membranous and cartilaginous portions1 in. above the bifurcation on the right side. Thedepth of the wound made closure difficult, but it wasachieved with interrupted black silk sutures. It wasout of the question to alter the site of the incision tofacilitate exposure. At once the anaesthetic problembecame less troublesome, and it was a little easierto keep the trachea and bronchi dry.The sternum was wired to the manubrium and the

manubrium to the clavicle and first rib. This resultedin some degree of stabilization. The wound wasclosed in layers with one tube in the right pleuralcavity and a second in the mediastinum.The immediate post-operative period was difficult.

Blood, secretions, and inhaled vomit were still presentand bronchoscopy was again necessary, this timethrough the tracheostomy. It was hurriedly donebecause the moment assisted respiration was discon-tinued the patient became deeply cyanosed. However,major secretions were cleared. The cuffed tube wasreinserted and assisted respiration continued. Imme-diately afterwards further difficulty in maintainingadequate ventilation was experienced due to a leftpneumothorax. At operation the left pleural cavitydid not appear to have been opened, so no tube hadbeen left in that side. This was rectified.The problem now was to decide how to maintain

adequate respiration. A radiograph taken in thetheatre showed both lungs fully expanded, though theright lung was extensively consolidated and the leftone less so. The trachea had been sutured and thechest wall stabilized, so it was anticipated thatparadox would be of less significance. In successionthe following measures were adopted:Maintaining Respiration.-The patient was allowed

to breathe spontaneously, but in a few seconds thiswas seen to be impossible. The paradox, despitemechanical fixation, was severe, the breaths wereconvulsive gasps, bronchospasm was marked, andintense cyanosis developed.Manually assisted respiration, using oxygen (100%)

at a respiratory rate of 40 to 44, maintained life, butits rapidity made it impossible to synchronize therebreathing bag with the patient's respiration. The

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THE CRUSHED CHEST

paradox was unchecked and anoxia and carbondioxide retention developed.A Bennett's respirator, using 100% oxygen and

maximal inspiratory pressures (20-25 cm. of water),was next tried unsuccessfully. The secretions, theparadox, and the intense bronchospasm provided sucha degree of respiratory obstruction that these maxi-mum inflationary pressures were too low, andcyanosis, sweating, and a raised blood pressure

resulted.Complete curarization and intermittent positive

pressure respiration proved the only method ofcontrolling the shattering paradox and providingadequate ventilation. The patient's colour improved,the pulse rate dropped to 100, and the blood pressure

dropped to within normal limits. Constantly recurringcopious secretions and intense bronchospasm per-

sistently caused great concern, as the inflationarypressures needed (35 cm. of water) remained very highand rendered two mechanical respirators (the Harring-ton-James and the Jefferson) ineffectual. Manualcontrol of respiration with complete paralysis was

therefore essential and was carried out with a standardBoyle's anaesthetic machine and circle type C02absorption. This was continued throughout the nightand during the next day, at a rate of 40 per minuteat a pressure of 20-35 cm. of water.The above measures, with frequent tracheobronchial

toilet, controlled the respiratory difficulties, althougheach bronchial suck-out was accompanied by cyanosis,sweating, and a rise in blood pressure.

At 6.30 p.m. on the first post-operative day atropine,1 mg., and "prostigmin," 2.5 mg., were given toreverse the curare and observe any change in respira-tory efficiency. Paradox was still severe and bothspontaneous respiration and assisted respiration were

inadequate.At 7.30 p.m. the patient's condition had deteriorated,

and he had a pulse rate of 150 and a blood pressure

of 85 mm. of mercury. Controlled respiration was

restarted. The blood pressure at once rose to 130 mm.of mercury. Fluctuations in pulse and blood pressure

recurred frequently throughout the night. The sodalime had to be changed at 15-minute intervals.Pethidine, soluble phenobarbitone, and a nitrousoxide-oxygen mixture (50%) sedated the patient.

Controlled respiration was continued in the secondpost-operative day, but as the curare wore off it was

found that respiration could be manually assisted.Despite this, in the early afternoon the patient'scondition was poor and his pulse rate was 144. Theinflation rate was 46 and it was virtually impossibleto clear the bronchial tree. A bronchoscopy resultedin some improvement.At 6 p.m. the curare was reversed and a further

attempt at spontaneous respiration made. It was

unsuccessful, as also was assisted respiration. Con-trolled respiration was induced and maintainedthroughout the night. During the period of reversalthe first signs of returning consciousness appeared.The patient opened an eye and gazed with a sightlessstare. He did, however, respond to painful stimuli.

On the third post-operative day there was furtherimprovement in the conscious state. Manually assistedrespiration with smaller intermittent doses of curarewas a little easier to maintain, and an attempt toinduce spontaneous respiration was a little moresuccessful. This time it lasted 40 seconds before thepatient became distressed. Throughout the nightcontrolled respiration was continued.On the fourth post-operative day a chest radiograph

showed extensive bilateral pneumonia. Throughoutthe day mechanically assisted respiration with aBennett's respirator using a 60% oxygen-air mixturewas alternated with manually assisted respiration.Inflationary pressures were still high (20-25 cm. ofmercury). Alevaire and neo-epinine added to theinspired mixture helped to diminish the bronchospasm.A further attempt at spontaneous respiration was

made. There was an improved response, the patientbreathing spontaneously for one minute. Throughoutthe night, to prevent exhaustion and for the sake ofsafety, respiration was alternately manually controlledor assisted.This progressive pattern continued for some days.

the paradoxical respiration gradually lessened, butsevere bronchospasm, secretions, and inhalationpneumonia made assisted respiration of some formnecessary. Alevaire, neo-epinine, adrenaline in oil,and an intravenous aminophylline drip were all usedand ultimately helped in combating these features.Constant tracheobronchial suction, although distressingto the patient, was absolutely essential every hour andsometimes more often.Each day spontaneous respiration continued for a

little longer. On the seventh post-operative day itcontinued for 20 minutes. It was then felt safe tomove the patient from the recovery ward, and this wasdone on the eighth post-operative day, but the shorttrip to his room proved most distressing and assistedrespiration was necessary for some hours. Through-out the night mechanically assisted respiration wascontinued. This was the first night that eithermanually assisted or controlled respiration wasunnecessary.On the ninth post-operative day assisted respiration

through a cuffed tube was alternated with spontaneousrespiration through a metal tracheostomy tube. At11 p.m. on this day, while the metal tube was in place,bronchospasm suddenly became severe and secretionscopious. This had been initiated by the passageof a duodenal tube a few minutes earlier. The metaltube was removed in order to carry out bronchialtoilet. Just as the tube was removed the patientvomited. He inhaled a considerable quantity and atonce became unconscious and pulseless. The vomitwas sucked out, the cuffed tube was reinserted, andmanual inflation with 100% oxygen begun. His pulsereturned and blood pressure rose to 250 mm. ofmercury. At no stage had he been without a doctorin attendance. This factor alone saved him on thisoccasion. Slow improvement took place and threehours later he was asleep and his colour quitereasonable.

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On the eleventh post-operative day his conditiongradually deteriorated throughout the morning. Jiehad great respiratory difficulty, assisted respirationagain becoming necessary. The chest radiograph wasworse than ever. Both pleural cavities were

needled and 26 oz. of blood-stained fluid removedfrom the left side. A further bronchoscopy wasnecessary when the entire bronchial tree was seen tobe red and dotted with pyogenic membrane. Loosedebris was removed. These measures resulted in someimprovement and this was reflected in improving chestradiographs.

Progress was now rapid, and on the fourteenth post-operative day the patient breathed spontaneously for24 hours. The tracheostomy was kept open with a

large plastic tube for a further two weeks, as the coughwas quite inadequate to remove bronchial secretions.He was discharged on January 8, 1959.We have deliberately avoided mentioning the

problems confronting us with regard to theabdominal injury, the femoral fractures, and themediastinal infection.CASE 3.-J. H. (59/555), a man aged 73, was

involved in a car accident on July 30, 1959. Onadmission he was stuporose, anoxic, hyperpnoeic, withgross paradox of the entire right anterior chest andaxilla. There were multiple fractures of the second toeighth ribs on the right and surgical emphysema ofthe face, chest, and upper abdomen. The abdomenwas very distended. The pulse rate was 106/min.and the blood pressure 85 mm. Hg. A chest radio-graph revealed a right haemopneumothorax withpatchy atelectasis on the left side.The patient was given a general anaesthetic and

curarized, a large amount of blood-stained mucus firstbeing removed from the bronchial tree. Paradox was

abolished at once. An intercostal catheter wasinserted into the right side of the chest and 22 oz.

of blood removed. The lung re-expanded. Atracheostomy was performed and further blood-stainedmucus obtained.

After these procedures a period of three hours wasspent in converting the patient from manuallycontrolled respiration to mechanically assisted respira-tion. As in Case 2, he was at first unable to adjustto the mechanical respirator due to secretions andspasm, but at the end of three hours he was comfort-able with paradox controlled at 15 to 20 cm. H20on a Bennett's respirator. In the ensuing three daysimprovement was steady, though periods of C02retention with rises in blood pressure necessitatedfrequent distressing tracheal suction.On August 4, 1959, four days after admission

at 6.30 a.m. his condition suddenly deteriorated.A radiograph of the chest revealed a righteffusion and some left-sided consolidation. His pulsewas 180/min., his blood pressure was unrecordable.He was moribund, in profound circulatory failure,though neither cyanosed nor sweating. A changefrom mechanical to manually assisted respiration was

unavailing. A right chest aspiration produced 1,000

ml. of blood without improvement and trachealsuction failed to improve his condition. However,considerable resistance to manual inflation wasobserved, so the cuffed tube was removed. At oneend of the tube was a tough flap of adherent fibrin andold clot, acting as a valve. It allowed the sucker topass through but at once flapped into place. A cleantube was inserted and the respirator restarted.Improvement began at once and was maintained.Recovery was then rapid. The patient was dischargedon August 25, 1959.CASE 4.-H. T. (59/4276), a man aged 38, was

injured in a head-on collision on February 26. 1960.He suffered multiple fractures of the anterior ends ofthe left second to seventh ribs, a transverse fractureof the sternum, and a compound fracture of the lefttibia and fibula. The right forearm and hand werevirtually roasted. He was admitted to the HornsbyHospital under the care of Mr. W. Taylor.He was found to have a left haemothorax and

severe bilateral paradox. He was transferred to theThoracic Surgical Unit at St. Vincent's Hospital.On admission an intercostal catheter was insertedinto the left chest, 1,500 ml. blood was removed, andthe left lung re-expanded. Paradox was still gross,so he was given a general anaesthetic and curarized.A tracheostomy was performed and controlled respira-tion instituted. The conversion period from controlledto mechanically assisted respiration lasted two hours.Next morning he again had considerable difficulty

with paradox. A radiograph of the chest revealeda right pneumothorax, which was corrected and theparadox disappeared.The patient ran a swinging temperature (1000 F.-

1020 F.) from admission. A radiograph of the cheston March 10 revealed a large left effusion, whichproved to contain pus, and on March 11 a lefttotal empyema was drained. Despite this, his condi-tion deteriorated. On March 14 he developed atrialfibrillation with a rate of 160; he was dis-orientated, and there was a pericardial friction rub.A radiograph of the chest showed a distendedpericardium, which was needled and heavilyblood-stained offensive fluid withdrawn. A smearcontained Gram-positive cocci. The pericardium wasat once drained. The blood culture grew a haemolyticStaphylococcus aureus. Heavy doses of chloromycetinand erythromycin were begun. Thereafter the patientmade a good recovery, though it was many monthsbefore he had a useful right hand.We considered that the lesions predisposing to

the septicaemia and suppurative pericarditis werethe fractured sternum and the extremely infectedforearm and hand.CASE 5.-Mrs. J. P. (131/60), aged 38 years, was

standing beside a traffic signal with her two childrenwhen all three were hit by a semi-trailer. Thedaughter was killed. T-he son is the subject of Case 6.She was admitted to Lewisham Hospital in a

severely shocked and stuporose state. The skin had

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been virtually torn from both legs below the knees.This, apparently, was looked upon as the majorconsideration. She was transfused and taken to theoperating room. During the course of the anaestheticthe anaesthetist noted increasing difficulty in inflatingthe chest and a little later noted gross bulging of theright anterior chest followed quickly by extensivesurgical emphysema. Further difficulty was experi-enced following the appearance of considerablequantities of blood-stained sputum.She was seen by one of us (H. W.) at this stage.

A radiograph in the theatre demonstrated multipleright upper rib fractures, a right haemopneumothoraxwith tension and mediastinal shift, and a contusedleft upper lobe.An intercostal catheter was inserted into the left

chest and 14 oz. of blood removed, after which thecatheter was connected to a suction pump. The lungre-expanded. A tracheostomy was performed. Atthe end of the operation on the legs a conversionperiod of seven hours was necessary before the changefrom manually controlled to mechanically assistedrespiration was complete. Bloody sputum from thecontused left lung and a fracture dislocation of thefirst lumbar vertebra with corda equina symptomsnecessitating recumbency were two other factors whichmade conversion troublesome.As soon as stabilization with a Bennett's respirator

was achieved progress so far as the chest was

concerned was excellent. A radiograph takenon the fifth post-operative day showed completeexpansion of the right lung and clearing of thecontused left upper lobe.Open reduction of the lumbar vertebra was carried

out on March 10. After this progress was satisfactory,although the leg injuries delayed the patient'sdeparture from hospital for many months.

CASE 6.-D. P. (2548/59), a boy aged 7, was

admitted to Lewisham Hospital on March 2, 1960.He had been knocked down by a semi-trailer a fewminutes earlier. His pulse was 120 and blood pressure

105/60 mm. Hg. The right lower chest and abdomenwere badly bruised. A radiograph of the chestdemonstrated some contusion of the right upper lobe.During the night the pulse rate rose to 140/min. and

the blood pressure dropped to 95 mm. Hg. Therespirations became increasingly shallow and grunting.A chest radiograph early the next morning demon-strated a fluid level at the right base. In a furtherradiograph two hours later the level had increased insize. There was neither cough nor sputum.

Right thoracotomy was performed at once. Thepleura over the lower lobe was intact, but the lobewas virtually gangrenous. It was excavated and filledwith blood clot. The upper lobe was moderatelycontused. A lower lobectomy was carried out. Con-valescence was satisfactory and the boy was discharged10 days later.CASE 7.-Mrs. L. A. (610/60), aged 49, was admitted

to St. Vincent's Hospital on July 31, 1960. A car

crashed head on into the side of the car in which shewas travelling and she received the full impact on theleft side.On admission she was dyspnoeic and cyanosed. The

left side of her chest was " wobbly." A radiographrevealed what was virtually a left thoracoplasty. Theleft clavicle was fractured.A tracheostomy was performed at once and

mechanically assisted respiration begun. Theparadox was controlled within five minutes. Duringthe next few days the physiological disturbance waswell controlled. Thirty-six hours after admission a leftpneumothorax occurred which necessitated an inter-costal catheter. At the end of 10 days it was stillpresent and air was still leaking. For this reasonleft thoracotomy was performed. Five sharp spikesof ribs were projecting into various parts of thelung. These were removed and the pulmonary lacera-tions oversewn, and an attempt made to wire thechest. Although six of the fragments were wired, thefutility of the procedure was soon apparent and theattempt was discontinued.

Respiration was mechanically assisted for two daysafter operation. It was then discontinued becauseparadox was fully controlled and the lung completelyexpanded. Thereafter recovery was rapid. She wasdischarged on September 4, 1960.CASE 8.-R. L. (578/60), a man aged 50, was

involved in a car accident on May 29, 1960.On admission he was deeply unconscious with a

fixed dilated pupil. There were extensive scalplacerations and multiple left rib fractures, severeparadox, and left pneumothorax.

Parietal burr holes were made, but neither extraduralnor subdural haematomata were found. He wasconsidered to have extensive cerebral damage withbrain swelling, and his prognosis was regarded as bad.

Despite the cerebral state the left chest wasdecompressed, a tracheostomy was performed, andparadox was controlled by assisted respiration.The response to the establishment of normal

respiration was immediate. Within minutes the stateof consciousness improved and in an hour he wasconscious and co-operative. He made an uneventfulrecovery.

COMMENT

AIR LEAK.-The air leak is either into the media-stinum and tissues or into the pleural cavity. In thecase of a pneumothorax, even if the leak is con-tinuous, management by means of an intercostalcatheter and suction pump is a simple matter. Ifthe air leak is severe and continuous, managementis a different problem, for then the assumptionmust be that the size of the opening is large orthe site of the opening is probably in a major airpassage.

Size of the Opening.-In Case 2 it was notapparent that the air leak was large until such

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time as an attempt at controlled respiration hadbeen made. The increasing emphysema and theleak of air from the small subclavicular incisionswere then obvious with every squeeze of the bag.

Site of Leak.-Upon the site of the leak willdepend where air will appear. Rupture of theright bronchus or distal left bronchus, both asso-

ciated, as they are, with the reflection of visceralpleura on to the mediastinum, will almost certainlyproduce either a right or left pneumothorax. Thereare many reports of such cases. Rupture of thetrachea or proximal left bronchus, much more

deeply placed, will always produce mediastinalemphysema but not always pneumothorax. Tenreported cases of tracheal rupture have been foundin the literature (Table I). Of these, six hadmediastinal emphysema alone, two had mediastinalemphysema and pneumothorax, and in two it wasdifficult to be sure.

The surgical approach of bilateral anteriorthoracotomy in Case 2 was decided upon afterconsideration of the following points: (1) Theballooning of the sternal area with each inflation

suggested the mediastinum as the site of the leak.(2) The absence of a continuous leak of air intothe right pleural cavity suggested that the openingwas above the right bronchus. (3) It was

impossible to make an adequate tracheobronchialinspection with a bronchoscope. (4) Thereappeared to be some possibility of controlling theparadox by fixing the fragments with wire.(5) Respiration was best controlled and maintainedwith the patient supine.

There are insidious forms of air leak with whichwe are being continually confronted. In thesecases the patient is admitted without a pneumo-

thorax but suddenly, hours or days afteradmission, develops severe tension, or the patientis admitted with a crushed chest and pneumothorax.Partial control of respiration with a respiratoris instituted, but some hours later he becomesdistressed and is found to have a contralateralpneumothorax (Case 4). Or the patient is admittedwith severe multiple injuries and for some reasonis submitted to general anaesthesia without thetrue nature of the chest injury being realized.

TABLE ISUMMARY OF CASES OF TRACHEAL RUPTUREI_

Author

Barford(1906)

Age

4

Sex

M

Bickford Youngl Mand adultRobertson(1958)

Dark and 6 M

Dewsbury(1955)

Moty and M

Guibal(1907)

Patrick 34 M

(1917)

Richards M

and Cohn(1955)

Rolleston(1891 )

Schonberg 20(1912)

Seuve 74(1873)

Thompson 34and Eaton(1955)

M

M

M

M

Cause Clinical Aspects Diagnosis Pathology Treatment

Surgical - Left bronchus Nilemphysema detached fromwithout trachea. Trachealpneumothorax rupture

Steering Surgical On fourth day IRupture on the Right thora-wheel emphysema andi when lear seen right side at junc- cotomy and

pneumothorax at broncho- tion of mem- closure of theon the fourth scopy branous and rentday cartilaginous

parts

Fell 10 ft. Surgical On clinical - Right thora-emphysema, grounds cotomy withright pneumo- right upperthorax lobectomy

and trachealrepair

Surgical Both bronchi Nilemphysema separated fromwithout tracheapneumothorax

Surgicalemphysemawithoutpneumothorax

Car Surgicalaccident emphysema

withoutpneumothorax

Left bronchusdetached fromtrachea

-Bronchoscopyand finding astricture

CaughtbetweenbuffersWheel of Surgicalbus over emphysemachestCrushed Right pneumo- On clinicalby thorax, little aspectsconcrete surgicaltile emphysema

Post-operative Result

Death

Spasm for 30 Recoverymin. post-operativelybeforespontaneousrespiration

- Recovery

Died

Nil

Permanenttracheotomy

Rupture of trachea Niland pulmonaryartery

Trachea trans- Nilversely severed

Ruptured trachea Nil

Right thora-cotomy withright upperlobectomyand repair oftrachea

Died

Alive

MDied

Died

Died

Recovery

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During the operation the anaesthetist finds thecondition deteriorating and cannot inflate. A radio-graph on the table reveals a unilateral or bilateralpneumothorax (Case 5). Although there is nothingparticularly new in these phenomena, they arebecoming more frequent and we cannot help butfeel they are associated with the increasing useof positive pressure breathing. They are of littlesignificance if recognized and managed promptly.To facilitate this a chest radiograph should betaken as soon as positive pressure breathing hasbegun, and repeated in six hours.

PARADOXICAL RESPIRATION.-When the chestwall is disrupted it leads to paradoxical respirationof a degree proportional to the degree of disrup-tion. Severe paradox is tantamount to an opensucking pneumothorax; it can be fatal, and iscertainly the most difficult of all the mechanicaldisturbances associated with chest injury to correct.Most cases can be dealt with by the simplemeasures of sand-bagging and strappingMuch has been written on the methods of fixing

the thoracic cage by means of wire and variousforms of splinting. It is our feeling that if theflail chest wall can be stabilized by such methods,then the degree of trauma is not severe and controlcan be achieved by simpler methods. We feelthat internal surgical fixation ought to be confinedto certain sternal injuries. On the other hand,injuries involving multiple bilateral comminutedrib fractures with gross paradox can never bestabilized by internal fixation but require imme-diate control of respiratory movements. Thepatient must be rendered apnoeic by some means,and intermittent positive pressure respirationbegun. Avery, M6rch, and Benson (1956) didthis by hyperventilation with a high-capacityrespirator. We found that it could be simply donewith intermittent doses of curare (5-10 mg. every30 to 40 minutes) and moderate hyperventilationby normal squeezing of the rebreathing bag of astandard anaesthetic machine. We found in Case 2(despite the wire) that assisted respiration, eithermanual or mechanical, would not control the para-dox and maintain an adequate minute volume.Similarly, in the early stages we found mechanicalrespirators unsatisfactory. Only manual compres-sion of the bag at 40 per minute with high inspira-tory pressure was adequate. This method provideda far more sensitive control over the constantlvchanging respiratory pattern.

Patients with such severe injuries requirecontinuous medical supervision, so this manualcontrol is no great additional burden.

In Case 2, as each day passed paradox diminished,and as stability improved and bronchial obstruc-

tion lessened it was possible to gain a littleco-operation from the patient. He was firstintroduced to manually assisted respiration, thenmechanically assisted respiration (Bennett), usingat first 100% oxygen and then a 40% mixture inair. Further improvement was noted by thegradual reduction in the inflationary pressuresrequired. Finally, assistance to respiration wasconfined to the nights to allow the patient torecover from the exhaustion of breathing all day.

In Cases 3, 4, 5, and 7, although the paradoxwas gross, inhalation, spasm, and secretions werenot troublesome and far less curare was used.Manually controlled respiration was continued fora much shorter time and it was easier to stabilizethe chest with mechanically assisted respiration.The most difficult period is the change-over

from manually controlled (where it has provednecessary) to mechanically assisted respiration. Atone end of the scale is the patient who is fullyconscious, has no bronchospasm and little secretion.A simple explanation, encouragement, and a littlepatience are all that is necessary. At the other endof the scale is Case 2, where the transition lastedone week.The change from hyperpnoea, cyanosis, and

paradox to calm quiet respiration withoutparadox, which almost always follows the use ofthese methods, is most striking.SEDATION.-The natural instinct of the medical

attendant caring for these patients is to sedatethem. This is particularly so when restlessness isa problem. It is our experience that distressingsymptoms such as restlessness have a definitecause (very often airway obstruction), and it is farmore important to find and eradicate the causethan to sedate the patient.The relief of pain and discomfort afforded the

patient merely by abolishing paradox and therebysplinting the rib fragments is so remarkable thatlittle analgesia is required.

BRONCHIAL OBSTRUCTION.-The most funda-mental of the principles of management of a chestinjury is that the airway must be clear. It is impos-sible to describe the enormity of the task inobserving this principle in Case 2.The difficulties were met with at three stages:

(1) The first six hours: We have outlined andemphasized the difficulties experienced before,during, and immediately after operation. Furthercomment is unnecessary. (2) The first post-opera-tive week: Throughout this week intrabronchialsecretions were excessive. The factors responsiblewere inhalation pneumonia with a solid rightlung and patchy consolidation of the left, due tothe initial flooding of the bronchial tree with blood

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and vomit, intense generalized persistent broncho-spasm, and severe purulent tracheobronchitis.

It was a full-time task for relays of doctors toattend to the patient during this stage. Duringthe first week the cough reflex was of no valueand suction (with sterile nylon catheters) had tobe supplemented with the occasional broncho-scopy. Each new man or woman on duty foundthe task a difficult one and each had to be coachedin the correct method of inserting the cathetersinto both right and left bronchi. Suction wasnecessary every half-hour and often morefrequently. Bronchospasm was ultimately con-trolled with the help of an aminophylline drip. Thespasm was always accentuated immediately aftersuction, but this was regarded as inevitable, as thesecretions had to be removed.During the second and third post-operative

weeks further troublesome factors appeared. Theywere the inhalation of gastric contents, thepyogenic membrane in the tracheobronchial tree,and the left pleural effusion.

It might appear at first to be a fundamentalbreach of treatment to allow the inhalation ofgastric contents. For the first week the patientwas maintained on intravenous fluids, as the gastricaspirate was copious and offensive. Throughoutthis period saliva continued to appear at thetracheostomy, having dropped through the cordsand passed through the large tracheal openingabove the cuff. This saliva was always carefullyremoved and the pharynx aspirated before theroutine hourly deflation of the cuff on the endo-tracheal tube.At the end of a week the patient was able to take

sips, but so long as the cuff was inflated most ofeach sip appeared at the tracheostomy. Eachtime anything was given by mouth the cuff wasdeflated, but co-ordination was poor and smallamounts always dropped into the trachea. ARyle's gastric tube was reverted to, but noamount of vigilance prevented the patient frompulling it out soon after it was inserted. For thisreason it was inserted every four hours. It wasjust after the passage of this at 11 p.m. on theninth post-operative day that the patient vomitedand inhaled a dangerous amount of vomit.At a still later stage the crusts from the pyogenic

membrane created further difficulties.It was our object from the start to remove the

cuffed tube at the earliest possible moment toprevent pressure necrosis and its sequelae in thetrachea. The cuffed tube was finally removed onthe fourteenth post-operative day.Throughout the period of artificial respiration

the inspired air and gases were humidified.

Alevaire with or without a bronchodilator helpedconsiderably to keep the bronchial secretions moistand mobile.We have come to appreciate the difficulties in

recognizing airway obstruction. None of the long-established signs may be present. In Case 3, thepatient almost lost his life because of our failureto recognize airway obstruction. This patientwent into circulatory failure and exhibited noneof the usual signs of airway obstruction. Trachealsuction made no difference. It was only whenincreased resistance to manual inflation was notedthat the cuffed tube was removed and theobstruction found.A similar episode occurred in one of our

patients, J.K., a boy aged 14, with severe tetanus.In the third week while under curare and con-trolled respiration his condition suddenly deteriora-ted. There was no sign of airway obstruction androutine tracheal suction was unavailing. Thecuffed tube was removed and there was the softbut firmly adherent plug of secretion in the end ofthe tube. At this moment cardiac arrest occurred.Cardiac massage through the left chest was donein the ward, another cuffed tube was inserted, andrespiration restarted. He recovered and now sixmonths later is well.

Restlessness as an early sign of airway obstruc-tion is very common. The moment the patientbegins to fidget it should be remembered. Wehave found this a valuable working rule. Ourfeeling is that if things are not right the airwayfirst of all must be suspected. It is our routine toremove the cuffed tube and suck out through thetracheostomy, if necessary with large metalpharyngeal suckers. This is more rapidly donethan bronchoscopy, is probably more effective,and, if done carefully, no more traumatic. Wefrequently find secretions of blood, mucus, orfibrin adherent to the end of the cuffed tube, andthey allow the sucker to pass but themselvesremain attached. It often takes a brisk rub witha brush to remove them.

Defective cuffed tubes are dangerous where thecuff herniates to one side. The lumen in thesetubes is easily occluded.

Pressure necrosis from the cuffed tube is a dangerand constantly in the forefront of our thoughts.Windsor, M. F. (1958), reported the occurrenceof tracheo-oesophageal fistula 1 cm. in diameterin a woman of 65 years. She had severe tetanus,had been curarized, and had been on controlledrespiration for five weeks. The fistula was success-fully closed after a cervical exploration. Maxwell(1960) has reported a fatal haemorrhage from anecrotic ulcer in the tracheal wall in a patient, a

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THE CRUSHED CHEST

woman aged 32 years, suffering from bulbar palsy.She had been on mechanically assisted respirationfor three weeks.A strict routine must be adopted so that the

cuffed tube is a snug fit without being tight; cuffinflation must render the circuit just airtight; anddeflation of the cuff, preceded by pharyngeal andtracheal suction for five minutes every half-hour,is imperative.Even when paradox is severe (Case 7), the chest

wall, once it is stabilized, begins to harden withgreat rapidity, sometimes in a few days. As soonas this happens we stop the respirator and deflatethe cuff. Certainly paradox is still present, butusually of little clinical significance, and it is notoften that a return to the respirator is necessary.ADDITIONAL FEATURES.-We have not previously

encountered the pathological state found in Case 6.A virtual explosion had taken place within thelobe, resulting in disruption and cavitation.Despite this the visceral pieura remained intact.The lobe was a blood-containing cavity, yet at nostage did the patient have a haemoptysis. This,together with the radiographic increase in the gas,suggested a pre-operative diagnosis of traumaticdiaphragmatic hernia, although we had never seenbowel presenting posteriorly in the right side ofthe chest following injury.The phenomenon of the response of the central

nervous system to adequate respiratory inter-change as demonstrated in Case 8 is a featurewhich we note with increasing frequency. Asimilar phenomenon has been a gratifying experi-ence on a number of occasions after tracheostomyhad been performed in the management of casesof cerebral trauma.

Severe violence, multiple injuries, and an elderlysubject (Case 3) is a combination which reallytaxes the resources of a hospital. Survival rateswith controlled or assisted respiration are instriking contrast to mortality rates before suchmethods were available.

CONCLUSIONThere are certain general considerations upon

which we wish to comment.The severe case is and will remain an almost

purely clinical problem. The changing patternsoccur with great rapidity and at any time, and theclinician must be able to recognize them withoutthe help of the laboratory, for frequently theyneed immediate attention.

These changing patterns demand constantvigilance by experienced observers. We believe(and practise) that while respiration is beingassisted a doctor must be present. On threeoccasions (Cases 2, 3, and J.K., a boy withtetanus) life was saved by attention to this rule.

In Australia, a country of long distances, wehave learned that patients with severe chestinjuries, no matter what the risk, must be trans-ferred to a large unit. Vigilance can only besupplied by a large tboracic unit. (We are indebtedto the R.A.A.F., which is always ready to take usto or bring patients from inaccessible places.) Anintercostal catheter can be inserted, a tracheostomycan be done, and assisted respiration can bestarted anywhere, but they cannot be supervisedanywhere.We have recently had the experience of trying

to sustain life in a native woman from TrobriandIsland, who developed a post-operative tubercu-lous spread in the right lung following removalof her destroyed left lung. In the first two post-operative days convalescence was uneventful, butas the right lung became more opaque respirationbecame more difficult. Very soon mechanicallyassisted respiration was no longer of avail. Life,however, was sustained for a further three daysby manually controlled respiration with highinflationary pressures. Efforts were only discon-tinued when these pressures burst the lung.The point we wish to make is that the perfect

respirator has not yet been made. There are manygood ones, but where severe paradox, atelactasis,and bronchospasm are combined, none of themcan compare with manual inflation. That this islaborious we concede. That it will save manycrushed chests we are convinced.

We should like to thank the editor of the Australianand New Zealand Journal of Surgery for permissionto quote extensively from the February, 1960, issue.

REFERENCESAvery, E. E., Morch, E. T., and Benson, D. W. (1956). J. thorac.

Surg., 32,291.Barford, J. L. (1906). Lancet, 2, 1509.Bickford, B. J., and Robertson, P. W. (1958). Thorax, 13, 246.Dark, J., and Dewsbury, P. (1955). Ibid., 10, 62.Maxwell, D. (1960). Personal communication.Moty and Guibal (1907). Arch. Med. Pharm. milit., 1, 444.Patrick, J. (1917). Brit. med. J., 2, 359.Richards, V., and Cohn, R. B. (1955). Amer. J. Surg., 90, 253.Rolleston, H. D. (1891). Trans. path. Soc. Lond., 42, 42.Schonberg, S. (1912). Berl. klin. Wschr., 49, 2218.Seuvre (1873). Bull. Soc. anat. Paris, 48 (5 ser., 8), 680.Thompson, J. V., and Eaton, E. R. (1955). J. thorac. Surg., 29, 260.Windsor, H. M., and Dwyer, B. (1960). Aust. N.Z. J. Surg., 29,235.Windsor, M. F. (1958). Personal communication.

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THE CRUSHED - Thorax · THE CRUSHED CHEST paradox was unchecked and anoxia and carbon dioxide retention developed. A Bennett's respirator, using 100% oxygen and maximal inspiratory