Epidemiological Profile of Thoracic Trauma in Brazil: A Systematic Review

INTRODUCTION

Thoracic trauma (TT) is part of the main injuries found in trauma patients and corresponds to 25% of deaths in polytraumatized patients.^1,2 According to the World Health Organization (WHO), over nine people die per minute from some type of trauma, with a health expense equivalent to 12% to all diseases.^3–5 External causes are closely related to TT, such as physical assault, automobile accidents, and other forms of urban accidents, which are the third leading cause of death in Brazil, corresponding to 12.5% of all deaths in the country.² With high global prevalence, trauma is considered a public health problem, associated with high morbidity and mortality, in developed and developing countries.

Since 1980, deaths from external causes have increased in Brazil. However, the Brazilian Public Health System (SUS) only adhered to the codification of diseases in a data system in 1997.⁶ Thus, information has become essential for monitoring and creating means of prevention of this serious reality in the country.⁷ The national policy for the Reduction of Morbidity and Mortality from Accidents and Violence, established by Ordinance No 737/GM by the Ministry of Health May 2001, proposes preventive measures against accidents and violence, in addition to ensuring the treatment of the victims.⁸

Thoracic trauma is classified as being either blunt or penetrating. The most common cause of blunt trauma is motor vehicle collision (MVC), which is responsible for up to 80% of the injuries. Other circumstances include crashes, vehicles hitting pedestrians, acts of violence, and explosion injuries. Most penetrating injuries are due to gunshot wounds (GSW) and stab wounds (SW), which together account for 20% of all serious trauma in the United States.^1,9,10

Treatment of most thoracic lesions is done through chest tube thoracostomy associated with analgesia and ventilatory support. Only 15–30% of TT need thoracotomy or other invasive intervention.^10–15 In the United States, %3C;10% of blunt trauma requires surgical intervention, while in open trauma 15–30% will require surgery.¹

This study aims to provide an epidemiological analysis of TT in Brazil by means of a systematic review.

MATERIALS AND METHODS

A systematic review addressing TT in Brazil was conducted in the electronic databases of PUBMED/NCBI, SciELO, LILACS, MEDLINE, WHOLIS, COCHRANE, and WHO. The analysis also based its results through System of Death Information (SIM), which is the computing department of the Brazilian Public Health System (SUS), following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search took place by articles published from January 2008 to January 2018 using the keywords “Injuries”, “Thoracic Trauma”, “Drainage”, “Thorax”, “Pneumothorax”, “Hemothorax”, “Epidemiology”, “Traumatology Centers”, “Cardiac Trauma”, “Penetrating Wounds”, and “Chest Trauma”. Three variables present in external causes were analyzed: transport accidents (TA), intentionally self-inflicted injuries (ISII), and aggressions (AGRs). The analysis includes researches published in Portuguese and English.

The following exclusion criteria were applied: case reports of other trauma causes, animal studies, reviews of the literature, and studies that did not cover TT.

The Statistical Package for Social Sciences (SPSS) version 21.0 was utilized to analyze the results. The patients were divided into three groups according to the type of death from external causes [traffic accidents (TA), ISII, and AGRs] which were compared employing the Kruskal–Wallis test. p values <0.05 were considered statistically significant.

RESULTS

Initially, 760 studies were identified in the databases searched (390 in SciELO, 37 in LILACS, 108 in PUBMED, 35 in WHOLIS, and 490 in COCHRANE). Following exclusion based on title and abstract, 133 articles were selected for full-text analysis. Finally, 36 articles were selected as relevant to the present study on the TT epidemiological characteristics as shown in Flowchart 1. The findings by regions were also described (Table 1).

Describing the main characteristics of TT in the North, Westphal and Luiz showed that penetrating TT with a lethal anatomical score (%3E;15 points) associated with important vascular lesions, such as the aorta and vena cava, are the main predictors of death. In the Northeast region, Cuba and Bezerra, through the study of 168 cases, described that penetrating trauma as the most frequent type in TT, the majority being treated conservatively. On the other hand, some patients required surgical specialists and a high-level trauma support hospital, which is a need not compatible with hospital services offered in this region.

Souza et al. presented in their study the profile of TT victims in the Midwest region, consisting mainly of young men with SW or motorcycle accidents. Jorge et al. showed in that same region that the total number of homicides and suicides doubled in frequency and TA are approximately 90% higher than the official report, demonstrating that TT data in Brazil is underreported.

Potlabathin and Scapolan through the analysis of 400 cases and medical records of 100 consecutive, respectively, that the TT patients profile consisted mainly of young men, with chest wall trauma, resulting from blunt TT by a TA. However, Silva and Gawryszewewski reported that the high number of trauma cases in the region can be reduced by means of accident prevention measures, investments in traffic education programs, and improvement of public safety. Mesquita Filho et al. discussed the external causes of death, which are poorly known and addressed in the public health network in the Southeast region.

Naufel Júnior, Zanette, and Oliveira in a study carried out in the South region concluded that the profile of patients affected by blunt TT consisted of men aged between 15 and 29 years. Saldanha et al. compared the use of alcohol and drugs between men and women victims of TA, showing higher incidence in TT also in men. Broska Júnior et al. stated that the chest drainage time, hospital stay, and severe complications associated are factors that worsen the prognosis of TT victims.

Guevara Rubio et al. argue that the general epidemiological profile found in Brazil is similar to that of other countries, the main difference is found in the injury mechanism. Gawryszewewski and Giannini claim that homicides and TA are the main factors for increased morbidity and mortality in Brazil. Campeão et al. add by stating that trauma is an important public health problem in Brazil, being among the main causes of death. Edgecombe and Whizar-Lugo described that through a diagnosis during the investigation of primary and secondary evaluation, the rate of death by TT can be reduced according to ATLS.

The division between penetrating and blunt trauma can be analyzed through the three variables selected in the study: AGRs, ISII, and TA, where the total number of deaths was 934,588 (p = 0.99). Of this total, blunt chest trauma is represented by TA, responsible for 350,684 (37.5%) deaths being more prevalent in the Southeast 35.7% (p = 0.033), likely due to greater urbanization and road stretches, followed by the Northeast 28.4% (p = 0.99), South 17.4% (p > 0.99), Midwest 10.6% (p = 0.99) and North 7.9% (p = 0.73). In this same perspective, penetrating trauma accounted for 583,904 (62.5%) deaths, mainly caused by aggression (61%) and ISII (1.5%). Regarding deaths from aggression, the Northeast region has the highest incidence 39.9%. Deaths from ISII are more common in the Southeast (37.1%), followed by the South (27.3%), Northeast (18.7%), Midwest (9.8%), and North (7.1%) (Table 2).

Analyzed deaths in males (826,527) occurred due to aggression (63.9%), TA (34.7%), and ISII (1.5%). On the other hand, of the 68,550 deaths in females, the same categories represented the following figures: TA (59.6%), AGRs (39%), and ISII (1.5%). However, while comparing each cause separately, it is noted that men die mainly from the three categories: aggression (92.5%), TA (81.7%), and ISII (88.4%). Therefore, those male deaths occur especially by penetrating trauma (AGRs and ISII) and female deaths from blunt trauma, particularly TA (Table 2).

The object gunshot or stab wound (GSW/SW) used in the mechanism of open injury can be evaluated, the total of which, as previously stated, was 583,904 deaths (p = 0.99), and statistical analyses represented Northeast (p = 0.99), Southeast (p = 0.99), South (p = 0.04), North (p = 0.99), and Midwest (p = 0.04). Lesions due to GSW were responsible for 77.3% of the total number of penetrating chest trauma deaths and accounted for 79.3% of male deaths (Table 3).

From the GSW deaths, the Northeast is the main representative (41.1%), followed by the Southeast (28.2%), South (12%), North (10.2%), and Midwest (8.3%). Those caused by SW totaled 22.1%, which represents 86.7% of deaths in that region. The distribution between the regions is as follows: Northeast (33.1%), Southeast (26.8%), North (16.4%), South (12%), and Midwest (11.5%). In fact, according to female deaths, 60.9% were caused by GSW and 39.1% by SW.

In that sense, it is noted that lesions by GSW are the most prevalent in both sexes and the Northeast has the higher prevalence of the two categories (Table 3).

DISCUSSION

In TT, the determining injuries for immediate risk of death are airway obstruction, hypertensive pneumothorax, open pneumothorax, cardiac tamponade, tracheobronchial injury, and massive hemothorax. Those with a potential risk of death and should be diagnosed and treated on secondary evaluation are pneumothorax, hemothorax, pulmonary contusion, flail chest, blunt heart trauma, traumatic aorta rupture, and traumatic rupture of the diaphragm.¹⁶ Hence, penetrating or blunt chest trauma, as long as it is associated with these consequences of chest trauma, is subject to higher mortality as chest injuries correspond to the highest death rate during primary evaluation.

Lesions can also be divided into four large groups of associated injuries: chest wall, pulmonary, mediastinal, and diaphragmatic lesions.¹⁷ These lead to six main types of clinical situations: airway obstruction, hypertensive pneumothorax, flail chest, cardiac tamponade, open pneumothorax, and massive hemothorax.¹⁶ In addition, abdominal organs may also be affected—such as the liver and spleen—more often in thoracoabdominal or those due to a high energy mechanism.¹⁸ Therefore, early diagnosis and treatment are essential in the first hour of trauma (Golden Hour) and are associated with lower morbidity and mortality.^1,16,19

Chest computed tomography (CT) is considered a more sensitive method and should be used only in special situations and for stable patients.^20,21 The gold standard in the care of TT for blood detection in the pleural cavity and pericardium has been extended focused assessment with sonography for the trauma (E-FAST).^16,22 It can also be used in the detection of pneumothorax, with sensitivity similar to that of chest CT and higher than chest X-ray.^22–24

Of the total deaths in trauma patients, 25–35% are caused by TT.^1,2 The mortality with only one isolated chest injury ranges from 4 to 8%, however, it rises to 25% when another organ is reached and up to 35% when multiple organs are hit.¹³ Thus, according to the Brazilian Ministry of Health, about 30,150 trauma patients die during surgical treatment during the analyzed period (2008–2018). Therefore, it is concluded that, of this total, >10,000 people died from chest trauma in these 10 years.

In TT, 85% of victims normally are treated under ventilatory support, analgesia, and chest tube thoracostomy. Only 15–30% will require surgical treatment, in most cases severe patients who need some type of intervention, a fact that justifies the demand for trauma centers.^10,15,18

According to the Institute for Applied Economic Research (IPEA), in 2004 TA increased by 50.3% on Federal Highways, with a rise of 34.5% in deaths and 50% in general injuries. However, between 2010 and 2014, there was a reduction from 40 to 30% in the number of accidents and serious victims.²⁵ This information corroborates the results of TA found in our study, although the number is smaller, it is still necessary to reduce it even more. In Itajaí, a municipality in the state of Santa Catarina (South region), in 2019, 89% of TT were due to blunt injuries and 57% to TA.²⁶

Penetrating TT was responsible for more than half of the deaths from TT assessed, mainly due to external causes. A study published in 2009, points out that in Manaus (North region), TT occurred mainly owing to physical aggression, especially in males (98.8%).¹⁵ This fact corroborates with the results found in our study because the AGRs overcame self-harm and TA in the North of the country. Our data are in agreement with other studies carried out in São Paulo, Minas Gerais, Goiás, Paraná, and Maranhão, where penetrating trauma was predominant, mainly in males.^2,10,27–30

The high prevalence of TT in males between 20 years and 40 years may not represent greater access to health services, but a greater tendency to exposure to external causes.^31,32 Besides that, a study carried out in two hospitals in Porto Alegre compared risk behavior among men and women involved in TA. Such a study revealed that 70% of the 609 victims were men, and of these, 75.2% were drivers and only 18.6% of women involved in accidents were female drivers. Evidence pointed to higher use of alcohol, marijuana, and cocaine among men and higher use of anxiolytics among women.³³ Thus, males tend to be affected more by TA and get involved in violent situations, when compared to females.

In penetrating TT, there is a relationship between the type of weapon and the economic conditions of the study population. Stab wound predominates in poorer regions compared to the GSW.¹⁵ Literature data revealed a prevalence of penetrating trauma by GSW in Manaus, São Paulo, Goiânia, Recife, São Luis, and Itajaí.^{2,10,15,26,30,34}

The high rate of deaths by GSW and the difference between the Northeast and Southeast in deaths can be understood. According to IPEA, in 2010, in 20 microregions with the largest number of firearms in Brazil, 13 were located in the Northeast, 4 in the Southeast, 2 in the South, and 1 in the North. This fact confirms the distribution by regions regarding deaths to GSW. It is notable that, even after the Disarmament Statute in 2003—which prohibited the commercialization of firearms throughout Brazil—the reduction in the use of firearms has not occurred homogeneously in the country.³⁵

Through the data obtained by the SIM system, referring to “Deaths due to External Causes in the Brazilian Regions”, according to the analyses of TA, ISII, and AGRs, the only region that presented statistical relevance was Southeast presenting (p = 0.033) due to the extensive road providing a large number of TA. The North Region, although presenting a high rate of AGRs and with low population concentration and low income, did not demonstrate statistical relevance (p = 0.73). For the other regions, there was no statistical significance (p ≥ 0.5).

On the other hand, while analyzing deaths for penetrating TT in the Brazilian region, we found statistical relevance for GSW and SW in the South (p = 0.04) and the Midwest (p = 0.04) among the other regions, although the statistical significance is irrelevant (p ≥ 0.5).

During the literature search for this systematic review, the deficiency of data compilation was an important and present factor observed by the authors. In Brazil, there is no consistent database that presents reliable information about TT. The main studies on chest issues are descriptors of surgical procedures and techniques, leaving a gap on the epidemiology and specific characteristics of TT in Brazil. Thus, in this study, we seek to present the main epidemiological characteristics of TT in the country to fill this need by offering concisely compiled information.

CONCLUSION

According to our analysis, TT is more prevalent in males. The most common type is penetrating TT and the highest mortality occurred due to GSW. As for blunt traumas, they are mainly caused by TA.

There is a need for a more accurate compilation of specific data regarding TT to ensure a safer epidemiological panorama since in Brazil the characteristics of TT are heterogeneous and thus, the lack of reliable data can demonstrate a fictitious reality of information.

CONTRIBUTORSHIP STATEMENT

All Authors equally contributed to the execution of this text, discuss planning, conduct, reporting, conception and design, acquisition of data, analysis, and interpretation of data: Gabriel Antonio Roberto, Carolina Magalhães Britto Rodrigues, Sthefano Atique Gabriel, and Rodrigo Sardenberg.

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