[Development of treatment of severe thoracic injuries]

About 25 p. 100 of cases of closed trauma of the thorax may be classified as severe, for they rapidly endanger life. Their treatment has made considerable progress since the report of J. Dor and H. Le Brigand in 1960. However, when severe trauma is treated, the mortality has remained unchanged over the last ten years. The treatment of fractures of the sternum includes respiratory assistance and internal fixation of the fractured bones, these two methods together, when correctly applied, give good results. Endothoracic lesions are now better recognised. Hemothorax and pneumothorax are now treated by a well recognised method. Visceral lesions, such as bronchial rupture, or major vascular ruptures, e.g. aorta, and heart lesions may be diagnosed at an early stage and be operated on more often. On the other hand, it is now better recognised that diffuse pulmonary lesions, e.g. pulmonary contusions or "shock lung", which is usually treated by artificial respiration alone, still may have a poor prognosis in some cases. From this it results that many surgical teams have enlarged the indications for early thoracotomy in the same way as laparotomy is more often carried out in abdominal trauma. In fact, these indications require circumspection and thoracotomy should only be carried out in specialised thoracic surgery units. If this is not available, aspiration, drainage, tracheotomy, continuous extension, are still applicable, but it is also necessary for them to be carried out correctly; if not, failures and complications of these minor measures are frequent. The use of these methods has shown the existence of therapeutic failures, including major bilateral bony lesions, diffuse severe lung injuries with resistant anoxia, complex multiple injuries with thoracic involvement and, finally, combined thoracic and cranial lesions, the mortality of which is about 50 p. 100. These facts explain why treatment of severe thoracic trauma gives variable results. The mortality varies from 12 to 15 p. 100, in some series up to 50 or 60 p. 100 These discrepancies may be explained by different modes of recruitment of the services, some of which receive a large number of very severe cases of multiple injury with a high mortality. However, over the last 15 years, one may consider that the general prognosis of severe thoracic trauma has improved considerably.