Combined chest and abdominal trauma in pedestrians injured during car accidents

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Combined severe injury caused by road traffic injuries and falls from heights is a very global medical, social and economic problem all over the world [1]. The main contingent of victims of Combined injury CI is people of the most able-bodied age from 15 to 49 years. Worldwide, more than 5 million people die from various injuries every year. For people in the age groups from 5 to 49 years, injuries occupy the 1st place in the overall structure of mortality in the population [2, 3]. CI is defined as a syndrome of multiple and combined injuries, the total severity of which on the ISS scale is 17 points or more [4, 5].Not less than 75% of patients with CI show damage to the head structure, which in 50-60% of cases is combined with chest and abdominal trauma. Such conditions increase the mortality rate from head trauma by more than 2 times [6]. Awareness of the specific features and the need for a new approach in providing medical care to victims contributed to the allocation of CI in a separate category [7].

Currently, there is an increase in abdominal injuries in the composition of CI reaching up to 38% , while the mortality rate remains high, ranging from 18 to 65% [8, 9].  Liver injuries are more dangerous among closed injuries of the abdominal cavity, especially in cases of crushing of its parenchyma, accompanied by intra-abdominal bleeding, and the mortality rate can reach up to 34-35% [10, 11]. These data dictate the need for immediate surgical intervention for liver injuries. A delay in surgery of more than 6 hours due to diagnostic and tactical errors can lead to a fatal outcome in patients with abdominal injuries [12].

These data dictate the need for continuous improvement and development of new methods for early diagnosis and treatment of patients with CI at the prehospital and hospital stages, as well as the adoption of necessary comprehensive measures for injury prevention.

From a forensic point of view, CI is of interest in terms of establishing thanatogenesis, qualifying the severity and determining the mechanogenesis of trauma, as well as identifying and evaluating defects in medical care at various stages. These and other aspects of CI for solving the problems of forensic medical examination (FME) are insufficiently studied and investigated [13, 14].

Purpose of the study. To identify the features of forming an assessment of the mechanism of damage to the structure of the chest and abdominal organs in pedestrians when they collide with moving cars.

Materials and methods. A forensic medical examination was carried out in relation to 215 corpses, the faces of pedestrians who died in collisions with moving cars. Among the dead men-173, women-42. The victims range in age from 14 to 75 years. In 190 cases, pedestrian collisions occurred with modern passenger cars, of which the most common (100 cases) were with Daewoo cars.uz Nexia; in 17 cases - with passenger cars of old brands; 4 cases - with trucks and passenger cars, and in 4 cases - car brands are not established. According to the materials of the preliminary inquiry (investigation), in most cases the collisions were front and front-edge.

Research results and their discussion. According to the results of a forensic medical examination, 206 (95.8%) of the dead pedestrians had CI of 2 or more body parts, and only 9 (4.7%) of the dead had an isolated traumatic brain injury (TBI).  Injuries of two or more body parts with fractures of the extremities (120) – 55.8% and CI of the head, chest, and abdomen (50) – 23.3% prevailed. Injuries to the head structure -TBI both as part of the CI and in an isolated form-were noted in almost all the dead pedestrians.

As part of the CI, damage to the structure of the chest and chest cavity organs was noted in 184 cases (85.6%), while 17 dead pedestrians (7.9%) had fractures of the clavicle, and fractures at its ends predominated in localization, which indicated their formation when victims fell on the road surface in the 3rd phase of car injury.

Localization of rib fractures in pedestrians who died in a car injury is shown in Table 1.

Table 1.

Localization of rib fractures in pedestrians

Localization of fractures	Frequency of occurrence
right	31
left	34
on both sides	59
total	124
upper ribs (with 1-5 ribs)	45
lower ribs (with 6-11 edges)	15
upper and lower ribs	64
total	124
along anatomical lines:
- mid-clavicular	38
-near-thoracic	12
along axillary lines:
-anterior axillary	20
-middle axillary	10
-posterior axillary	16
scapular	12
paravertebral	16
total:	124

 

The table shows that 124 pedestrians (57.7%) had rib fractures along different lines with injuries to intercostal muscles and parietal pleura. Fractures were most often bilateral (59 out of 124), and fractures of the right and left ribs occurred to the same extent (31 and 34, respectively). In 64 cases (29.8%), fractures in the deceased pedestrians covered almost all the ribs (from rib 1 to rib 11), the localizations were dominated by fractures along the mid – clavicular and axillary lines, which were indirect in nature with signs of compression on the inner and sprains on the outer plates. This indicates that rib fractures in pedestrians are formed mainly in the 3rd phase of car injury - falls of victims on the road surface. Sternal body fractures were not uncommon (17).

From the thoracic cavity, 184 victims had the most pronounced hemorrhages in the mediastinum, in the roots and other parts of the lungs, as well as in the heart shirt, in the muscles of the heart and the walls of the main vessels, the intensity of hemorrhages prevailed in the lung tissues. Of these, 36 cases had ruptures of the lungs, heart, aorta, trachea, and heart shirt (Table 2).

Table 2.

Characteristics of injuries to the structure of the thoracic cavity organs in pedestrians

Nature of injuries	Frequency of occurrence
hemorrhages in the lung tissue	137
hemorrhages in the walls of the main vessels	10
hemorrhages in the heart shirt, mediastinal organs, ventricular walls of the heart	3
total	150
ruptures of the lung tissue with hemorrhages	27
ruptures of the aorta with hemorrhages	1
ruptures of the trachea with hemorrhages	1
ruptures of the heart and heart shirt with hemorrhages	5
total	34
Total	184

 

Injuries to the structure of the abdominal organs as part of the CI in pedestrians were detected in 172 cases (71% – - Table 3

Table 3

Characteristics of abdominal injuries in pedestrians who received CI in collisions with moving cars

№	Nature of injuries to the structure of the abdominal organs	Frequency
of occurrence 1.	Hemorrhages in the structures of the abdominal organs without violating the integrity of the internal organs	132
2.	Hemorrhages in the structures of the abdominal organs with violations of the integrity of internal organs and internal bleeding phenomena	40
	Of these:  with rupture of the liver	14
	with a ruptured liver, spleen	11
	with a ruptured spleen	4
	with kidney rupture	3
	with rupture of the bowel and mesentery	3
	with a ruptured liver, spleen, kidney	1
	with a ruptured liver and the diaphragm	1
	with a ruptured diaphragm, mesentery and colon	1
	with a ruptured liver and colon	1
	with rupture of the stomach and duodenum	1
	with rupture of the liver, stomach and kidneys	1
	Total:	172

 

From the above data, it follows that 132 dead pedestrians showed signs of bruising of organs and tissues, which were accompanied by pronounced hemorrhages in the suspension devices, walls and parenchyma of organs. In 40 cases, along with hemorrhages, violations of the anatomical integrity of organs, mainly the liver and spleen, were detected mainly in the form of ruptures, and sometimes in the form of a crushed parenchyma, which caused massive internal bleeding.

Damage to the integrity of the liver structure was noted in 29 (16.8%) dead pedestrians, while isolated damage to it was detected in 14 cases in the form of extensive ruptures of the parenchyma along the diaphragmatic and lower surfaces (10) and splintering of the parenchyma (4) with a violation of the integrity of the gallbladder. In the remaining 15 cases, liver injuries were combined with injuries to other internal organs, most often with injuries to the spleen (12). The noted damage to the liver and spleen structure was the main cause of death of affected pedestrians at the pre-hospital stage as a result of massive blood loss. As part of injuries to the abdominal organs, violations of the integrity of the spleen were also frequent, both in the form of isolated (3) and combined injuries to it (12) with injuries to other organs, most often with the liver (11). Ruptures of the diaphragm, stomach, intestines, mesentery of the intestine and kidneys were noted in isolated cases.

Bruising and concussions of internal organs in the form of hemorrhages in the ligamentous apparatus and abdominal tissues were detected in 60.8% of cases (132 cases out of 215). At the same time, both the parenchymal and hollow organs of the abdominal cavity – the stomach, intestines and their structures-were most traumatized. These data indicate that bruises of the abdominal organs, including ruptures of internal organs in pedestrians in collisions with moving cars, are formed in the 3rd phase of car injury -falls of victims on the road surface, which develops a general concussion of the body.

According to the literature, 50-60% of patients with CI have chest injuries, while injuries to the lungs and tracheo-bronchial structures are the most common causes of mortality in patients [5, 15, 16, 17]. The effectiveness of providing medical care to victims of CI at the prehospital and hospital stages depends to a certain extent on the severity of the injury. The most common and generally accepted assessments of the severity of injuries and conditions of victims are considered to be the Glasgow Coma Scale (GCS) – the Abbreviated Injury Scale AIS and the Injury Severity Scale ISS (derived from it). Recently, the assessment of the severity of injuries and the severity of the condition of victims finds its application in a new teaching-damage control (demage control), which implies the use of certain treatment methods for each interval of severity points, aimed at preventing serious complications [18]. CI requires specialized medical care as soon as possible after the injury ("Golden Hour"). It is believed that when providing specialized care within the first 60 minutes after an injury, there is a higher chance of saving the lives of victims (mortality up to 10%), and when the duration of such assistance is increased to 8 hours, the mortality rate increases to 75% [19]. In hospitals for patients with CI, the complex of necessary medical and preventive measures should be prompt, thoughtful, systematic and carried out in a certain sequence. Victims whose condition does not pose a threat to deterioration are examined in more detail [20].

Ermolaeva N. K. et al. (2013) based on the analysis of 102 people who were in the hospital and died within 7 days after injuries to the abdomen and retroperitoneal space, found that the origin of injuries to these structures was dominated by road accidents (52%), less often - domestic (beating) – 22.5%, catatrauma -18.6% and other circumstances (6.9%). In 36.3% of cases, mortality occurred within the 1st day, of which 43.2% patients died in the first 3 hours, as a result of traumatic and hemorrhagic shock, which had the most severe CI covering 3 or more anatomical parts of the body.  In the authors ' materials, injuries of the abdominal cavity organ occurred in 44.1% of cases with closed abdominal trauma, injuries of parenchymal organs and mesentery prevailed, while the volume of intra-abdominal bleeding was from 1.5 liters or more. It should be noted that in the authors ' materials, injuries to the abdominal organs with violations of their integrity were present in 77.5% (79 out of 102) of the deceased, while bruises of organs and tissues with manifestations of hemorrhages (hematomas) were present in 22.5 (23) of the deceased. In our observations, violations of the integrity of internal organs with closed abdominal CI were noted in 16.8% of cases. This is due to the fact that our observations included only a car injury, and in the materials of Ermolaeva N. K. et al. in addition to road accidents, there were also domestic injuries, catatrauma, compression and other types of blunt mechanical trauma [21].

According to Bazaev A.V. et al. (2015), liver damage in CI is most often (35.5%) combined with spleen injury, which is the main cause of an unfavorable outcome as a result of intra-abdominal bleeding, and therefore the choice of adequate methods of hemostasis is of particular importance [10].

In the morphological aspect distinguish 4 degrees of liver damage: I – superficial wounds to a depth of 2 cm, II – wound depth from 2 cm up to half of the thickness of the III- wound more than half the thickness of the body and through the gaps IV – the crushing of the liver breaks hepatic artery and vein, common bile duct, portal vein and damage juxta - plot of the lower hepatic veins [22, 23]. This classification is the most informative for the analysis of blunt injuries of the liver to establish the mechanism of formation of organ damage, depending on the circumstances and conditions of blunt injuries.

Conclusions.

 Among pedestrians who died in collisions with cars, injuries of two or more body parts with fractures of limb bones prevailed (120) – 55.8% and CI of the head, chest, and abdomen (50) – 23.3%. Injuries to the head structure (TBI) both as part of the CI and in an isolated form were noted in almost all the dead pedestrians.

Injuries to the chest structure and thoracic cavity organs were noted in 184 cases (85.6%). 124 pedestrians (57.7%) had rib fractures, which were most often (59 out of 124) bilateral, and fractures of the right and left ribs occurred to the same degree (31 and 34, respectively). In 64 cases (29.8%), fractures in the deceased pedestrians covered almost all the ribs (from rib 1 to rib 11), and fractures along the mid-clavicular and axillary lines predominated in localizations. From the side of the thoracic cavity, the most pronounced hemorrhages were noted in the area of the roots and other parts of the lungs, as well as in the mediastinal tissue, cardiac shirt, heart muscles and walls of the main vessels, which were often combined with ruptures of the thoracic cavity, in which the intensity of damage prevailed in the structures of the lungs.

The described nature of injuries to the structure of the chest and chest cavity organs made it possible to establish the possibility of their formation in the 3rd phase of car injury-the fall of victims on the road surface. Traumatic (hemorrhagic, pleuropulmonary) shock and hemopneumothorax were the main causes of prehospital injuries.

Injuries to the structure of organs and tissues of the abdominal cavity as part of the abdominal CI in pedestrians in collisions with moving cars are observed quite often (71.0%). At the same time, 80.8% of the dead pedestrians show signs of bruising of organs and tissues with pronounced hemorrhages in the suspension devices, walls and parenchyma of organs. In 23.2% of cases, along with hemorrhages, there is a violation of the anatomical integrity of organs, mainly the liver and spleen, mainly in the form of ruptures and often in the form of a crushed parenchyma, which are the cause of massive internal bleeding. Damage to the structure of the abdominal organs in collisions between pedestrians and moving cars is formed in the 3rd phase of injury-due to a general concussion of the body when victims fall on the road surface.

In the clinical and morphological aspect, the division into the severity of liver damage, taking into account the volume and depth of ruptures (fractures), is the most informative for establishing the mechanism of formation of organ damage, depending on the circumstances and types of blunt trauma.

 

About the authors

Sayit I. Indiaminov

Samarkand State Medical Institute

Email: antonina_amurovna@mail.ru
ORCID iD: 0000-0001-9735-0338

MD, Dr. Sci. (Med.), Professor

Uzbekistan, 140100, Samarqand, Amir Temur str., 18

Saidkosim N. Pardaev

Samarkand State Medical Institute

Email: said-03-10@mail.ru
ORCID iD: 0000-0002-9743-0482

MD, Cand. Sci. (Med.)

Uzbekistan, 140100, Samarqand, Amir Temur str., 18

Antonina A. Kim

Samarkand State Medical Institute

Author for correspondence.
Email: antonina_amurovna@mail.ru
ORCID iD: 0000-0001-9083-5105

Assistant Lecturer

Uzbekistan, 140100, Samarqand, Amir Temur str., 18

References

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