A NON FATAL IMPALEMENT INJURY OFCHEST
By Tanveer Ahmad,
Assistant Professor and Consultant Thoracic Surgeon
Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi
A young man presented in the Accident and Emergency Department of Jinnah Postgraduate Medical Centre with bleeding from a chest wound on the left upper chest in the fourth intercostal space in the mid axillary line. He was conscious, well oriented and gave history of something striking his left chest while he was hanging on a speeding open truck. On examination he was sitting up in bed (Fig 1). His pulse rate was 106/m and the blood pressure was 100/70 mmHg. His respiratory rate was 28/m with shallow breathing. He was sweating profusely and his extremities were cold to touch. He was in shock. Multiple large intravenous lines were set up and blood was arranged for transfusion.
There was a 2*2 cm bleeding wound on the left side of his chest as described earlier. A chest X- ray (Fig. 2) revealed a foreign body traversing the left chest space across to the midline.
Emergency Thoracotomy was planned. Thoracotomy through the bed of 5thrib, revealed a large metallic rod penetrating the left lung completely. It was only just visible through the lung parenchyma and was in contact with pericardium and luckily just short of penetrating the heart (Figs. 3&4). With care not to cause any excessive major vessel bleeding and using vascular clamps on the hilum, the foreign body was carefully extracted out of the lung. There remained a large parenchymal defect with bronchial leaks which were repaired with prolene 3/0. It is important to seal off any major bronchial air leaks otherwise the lung will not expand postoperatively and further complications like empyema cannot be avoided. There was associated bleeding from the lung and inter costal vessels. The bleeding was controlled with suture ligatures using silk size 0. The large defect in the lung contained a hematoma. This was extracted out and hemostasis was ensured.
Chest was drained using a size 36 Fr. Chest tube which was connected to the underwater seal. There was no major airleak on a pressure of 45 cm of water. Chest was closed in layers using the standard technique.
The patient made a remarkable recovery from his operation and the chest tube was removed on the 3rdpost operative day. He was discharged from the hospital on the 10thpostoperative day after his thoracotomy sutures were removed. Follow up in OPD was advised and no late complications were observed during a 3 months follow-up period.
Discussion
Impalement injuries, in which a large foreign body traverses or penetrates a body cavity or extremity in a through and through fashion and still is in place, produces a dramatic clinical picture. Such injuries are often lethal depending on the organs involved. There are few reports of impalement injuries limited to the chest (1-7). The most important principle of management is that the impaling object should remain insitu whilethe patient is rapidly transported to an operating theatre, as it can have a tamponade-like effect on damaged vascular structures(1-6).
Thoracic impalement is an uncommon injury and one of the most severe types of penetrating chest injuries. Only a few cases have been reported in which the patient recuperated without sequelae. The cardinal rule of management is leave the impaling object in situ have been well described (1,2,4,5,7).
Several factors are in force when patients suffer such an injury to the chest and still survive.
1. The patients are young, in good health, and therefore more resistant to massive injury.
2. Rapid transport to a well equipped hospital is very crucial. Chances of survival are high because probably injury is limited to lungs only and cardiovascular system is spared.
3. Generally, impalement injuries combine aspects of both blunt and penetrating trauma (1). The degree of damage depends on which organs are involved especially when the heart or great vessels are impaled; there is an extremely high mortality rate in cases where the heart or the great vessels are penetrated.
4. To avoid major bleeding, the impaled object should be removed under direct vision in a well-controlled environment (an operating room). The operation should begin as soon as the patient s general condition is stable (1-7), and blood should be available for transfusion.
5. Usual trauma management principles should be followed, including airway control and fluid resuscitation.
6. Understanding the full extent of the injury is extremely important to plan the appropriate surgical approach (5).
7. Mechanical ventilatory support is must for respiratory insufficiency, which is required in many patients.
8. Injured vital structures should be repaired primarily. All the necrotic tissues should be removed and wounds should be adequately debrided (damage control surgery)to avoid infection. Viable lung should not be sacrificed .Because the expanded lung is the best protection against empyema (2-6).
9. Every attempt should be made to secure hemostasis and air leaks before chest closure (1-6).
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