Impalement injuries of the chest

Difficulties in the Management of Impalement Injuries Sustained in Rural India

Impalement injury is said to occur when a blunt force causes a long object to penetrate a body part resulting in retention of the object in situ. We report two unusual cases of impalement from rural India: one, chest impalement by a hunting spear and the other, an extremity impalement by a rotatory tiller blade. Thoracic impalement injuries are very rare, and there is only one other published report of chest impalement by a spear (trident) in the modern era. There are only two published reports of extremity impalement by a rotatory tiller blade. We also describe the difficulties encountered in their management. Patient-1 sustained accidental impalement to the right hemithorax by a spear used for hunting wild boars, leaving a meter long shaft protruding from his body. This necessitated his transfer to the hospital on the cargo bay of a pickup truck and also precluded complete radiological investigations before surgery. In addition, the reversed barbed tip of the spear made the extraction difficult. Patient-2 sustained impalement through the right knee by a rotatory tiller blade which bound him to the machine. The blade had to be disconnected from the shank assembly of the tiller to extricate him. Due to the proximity of the blade to the popliteal vessels, vascular control was necessary before extraction. Both the patients took several hours to reach the hospital as the accident occurred in remote rural areas. However, both had a successful outcome after surgical removal of the impaled object by a multidisciplinary involvement. We also have reviewed the published literature and given our suggestions for the management of these unusual and difficult injuries.

Two lucky survivors of thoracic impalement in childhood: case report and literature review

BACKGROUND

Penetrating thoracic injuries are uncommon in childhood. Massive penetrating injury due to impalement is even more rare and has scarcely been reported. It has a dramatic clinical presentation and is often fatal, depending on the organs injured.

CASE PRESENTATION

Two boys presented with an unusual mechanism of injury. They fell from a height to be impaled by a large stick. Appropriate emergency medical service was not available and surgery was delayed by more than 24 h after the accident. Both children were labelled "lucky" as they survived the injury without any significant sequelae.

CONCLUSION

We discuss two new cases of pediatric thoracic impalement and perform the first literature review on the subject. Emphasis should be given to the initial care which comprises avoiding premature removal, rapid transport, resuscitation, anti-tetanus and antibiotics. All reported cases had a favorable outcome, even those managed within the constraints of low-income countries.

Sledge Hammer Impalement: a case report of challenges of managing a patient with a heavy pendant

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This patient suffered an impalement injury by falling on the upright handle of a sledge hammer.

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The hammer head was too heavy for patient transport hence patient was fixed to small sized but heavy hammer head.

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Patient had to be moved simultaneously with the sledge hammer.

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We argue that this meets the definition criteria for transfixion injury.

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We propose that transfixion injury be defined in terms of weight of the impaling object relative to the weight of the patient and ability to mobilize the patient and not necessarily by size of the impaling object.

Introduction

Impalement injuries are well defined. Transfixion injuries involve impalement and are defined in terms of fixation usually to a large object.

Case Report

We report a spectacular case of sledge hammer impalement in the neck where the patient was transfixed, albeit to a small object, requiring movement of the patient and the transfixing object as a single unit.

Discussion

The patient was fixed to the head of the sledge hammer because he was unable to move with the heavy pendant.

Conclusion

We argue that transfixion injuries should be defined in terms of weight of the object in relation to the patient‘s weight and the ability of the patient to move (with) the impaling object.

Penetrating thoracoabdominal injuries from multiple-spiked spear stabbing: Case report and literature review

Penetrating thoracoabdominal injuries carry high morbidity and mortality. Concurrent clinical evaluation and resuscitation followed by early surgery are associated with good outcome. In a resource-limited setting, plain X-rays are valuable in surgery planning. Impalement objects must only be removed at surgery.

Crowbar impalement: the PHEM perspective

A man in his 50s suffered an impalement on a crowbar after falling from the roof of a domestic shed. A helicopter-based prehospital emergency medical service team was called to assist in the patient's care. The crowbar had entered from the left-upper quadrant and was tenting the skin of the right iliac fossa. Analgesia and prehospital sedation were provided to facilitate extrication. A series of improvisations were carried out to support the logistics of transferring the patient using an air ambulance to the regional major trauma centre with the crowbar in situ. The patient was taken to the operating theatre without any imaging and a section of perforated bowel was removed. He made a full recovery and was discharged home 9 days postincident.

An unusual case of transpelvic impalement injury: A case-report

INTRODUCTION

Impalement injury is a rare type of mechanical injury following forceful insertion of projecting object into the body. Careful planning for removal of the impaling object is essential to decrease the blood loss and preserve the function of the injured organ.

PRESENTATION OF CASE

A 27 year-old male fell from 4m height over a U shaped projecting up metallic bar. The bar penetrated the left side of the pelvis and traversed through the left iliac bone causing a comminuted fracture in the supra-acetabular region extending to the left psoas muscle, injuring the viscera and causing fracture of the right femur. Exploratory laparotomy was performed and the metallic bar was pulled out from the sigmoid colon through the inlet of the injury. Intramedullary nailing was performed for femur fracture. The patient developed infection (Methicillin-sensitive Staphylococcus aureus and Escherichia coli) during the post-operative course that was successfully managed with antibiotic therapy. Finally the patient was sent home after a week in a good health condition.

DISCUSSION

Two surgical teams worked in sequence to fix the injuries starting with the trauma team followed by the orthopedic surgeons.

CONCLUSION

Impalement injury is a serious injury that needs a multidisciplinary team with a coordinated approach to achieve a favorable outcome.

Near miss for big red: a unique case of penetrating glass injury of the thoracic spine and posterior mediastinum

INTRODUCTION

A 42-year-old female with no significant comorbidities presented to our care with a penetrating glass injury to her mid-thoracic spine after falling backwards onto a table.

CASE PRESENTATION

A large fragment of glass was protruding from her spine, and multi-planar computed tomography imaging revealed protrusion through the thoracic spinal vertebrae with the glass shards located 2 mm from the aortic lumen. The management of this patient posed several challenges, including initial care of the patient, evaluation of potentially affected structures and the appropriate sequence of therapeutic interventions. After multidisciplinary discussion, our trauma, thoracic and neurosurgical teams formulated a diagnostic workup and two-step surgical approach to address her injuries.

DISCUSSION

Here we present the approach used by our team to successfully manage this type of injury. We hope this case report represents a platform for future discussion on best management approaches in patients presenting with the low-velocity penetrating thoracic, spinal and posterior mediastinal trauma.

Impalement Thoracoabdominal Trauma Secondary to Falling on Metallic (Iron) Bars: An Extremely Rare and Unique Case

Introduction

Penetrating thoracoabdominal injuries are potentially life threatening due to the associated hemorrhagic shock and visceral injury. Through and through penetrating injury with polytrauma is rarely encountered.

Case Presentation

Here we report on a 25-year-old male with penetrating thoracoabdominal injury caused by a metallic (iron) bar projecting from a pillar of a construction site after he fell down from a height.

Conclusions

Anesthetic and surgical management was difficult due to the inability to position in supine and rapidly progressing hemorrhagic shock. Surgical management for extraction of this iron bar and intensive monitoring and resuscitation resulted in an uneventful successful outcome.

Retained weapon injuries: experience from a civilian metropolitan trauma service in South Africa

INTRODUCTION

Retained weapon (RW) injuries are uncommon, but there is no current consensus on the best management approach.

METHODS

We reviewed our experience of 102 consecutive patients with non-missile RWs in a high-volume metropolitan trauma service managed over a 10-year period.

RESULTS

Of the 102 patients, 95 were males (93%), 7 were females (7%), and median age was 24 (21-28) years. Weapons: 73% (74/102) knives, 17% (17/102) screwdrivers, 5% spears, 6% (6/102) others [axe (1), glass fragment (1), stick (1), sickle blade (1), wire (1) and stone (1)].

LOCATION

8% (8/102) head, 20% (20/102) in the face, 9% (9/102) neck, 14% (14/102) thorax, 25% (26/102) abdomen, 23% (23/102) upper limb, 2% (2/102) lower limb. Four per cent (4/102) were haemodynamically unstable and proceed immediately to the operating theatre for operative exploration and weapon extraction. Imagining: 88 (86%) plain radiographs, 65 (64%) non-contrast CT scans, 41 (40%) contrast CT angiography, 4 (4%) formal angiography. Seventy-two underwent simple extraction, and 29 underwent extract plus open operation. One patient absconded. Specialist surgeons involved in extraction: trauma surgeons (74), neurosurgeons (10), ophthalmic surgeons (11) and ENT surgeons (4). Overall, 92% (94/102) survived to discharge.

CONCLUSIONS

The vast majority of patients with RWs will be admitted in a stable condition and haemodynamic instability was almost exclusively seen in the anterior thorax. The most common site was the posterior abdomen. Detailed imagining should be used liberally in stable patients and unplanned extraction in an uncontrolled environment should be strongly discouraged.

Successful management of a combined abdominal and thoracic trauma with rectal impalement: report of a case

Introduction. Combined abdominal and thoracic impalement injuries are a rare form of penetrating trauma. Nowadays, they occur more frequently as an accident and not so often as a deliberate violent action. Case Report. A 35-year-old man was admitted to our emergency department with chest pain and respiratory distress after he had reportedly slipped in his bathtub. Abdominal and thoracic imaging, including computed tomography (CT), confirmed a right-sided pneumothorax and a liver laceration without bleeding or further endoperitoneal trauma. A chest tube was placed. During his hospitalization in the first 24-hour period, he complained of abdominal and right shoulder pain accompanied by fever. A new abdominal and thoracic CT scanning revealed a rupture of the rectosigmoid, a rupture of right hemidiaphragm, and a foreign body in the thoracic cavity. The patient admitted that a broomstick was violently placed through his rectum, and he underwent a thoracotomy with an exploratory laparotomy. The foreign object was removed, the diaphragmatic rupture was repaired, and a Hartmann's procedure was performed. The postoperative course was uneventful. Conclusion. In cases of combined thoracoabdominal trauma, high index of suspicion is required when medical history is misleading and the injuries are not obvious immediately. A coordinated team effort in a well-organized trauma center is also very important.

Management of severe thoracic impalement trauma against two-wheeled horse carriage: a case report and literature review

Thoracic injuries in general are of great importance due to their high incidence and high mortality. Thoracic impalement injuries are rare but severe due to the combination of cause, effect and result. This study's primary objective is to report the case of a young man who was impaled by a two-wheeled horse carriage shaft while crashing his motorcycle in a rural zone. An EMT-B ferry was called at the crash scene and a conscious patient was found, sustaining a severe impalement injury to the left hemithorax, suspended over the floor by the axial skeleton with the carriage shaft coming across his left chest. As a secondary objective, a literature review of thoracic impalement injuries is performed. Cases of thoracic impalement injury require unique and individualized care based on injury severity and affected organs. Reported protocols for managing impalement injuries are entirely anecdotal, with no uniformity on impaled patient's approach and management. In penetrating trauma, it is essential not to remove the impaled object, so that possible vascular lesions remain buffered by the object, avoiding major bleeding and exsanguination haemorrhage. Severed impaled thoracic patients should be transferred to a specialist centre for trauma care, as these lesions typically require complex multidisciplinary treatment. High-energy thoracic impalement injuries are rare and hold a high mortality rate, due to the complexity of trauma and associated injuries such as thoracic wall and lung lesions. Modern medicine still seems limited in cases of such seriousness, not always with satisfactory results.

Kunnur V, Kushwaha BB, Kushwaha R. Penetrating injury of pelvis, abdomen and thorax in a child with a trident (trishula)

Penetrating abdominal injuries are uncommon in the pediatric age group and are associated with a high mortality. A seven year old girl suffered penetrating injury to perineum when she fell onto the trident (trishula - traditional three pronged spear) implanted alongside Lord Shiva's idol. The rod caused perforations of the transverse mesocolon, ileum at 3 places, right lobe of liver, diaphragm, parietal pleura, and exited from 7th intercostal space. Surgical repair of each damaged site was undertaken. Despite delayed presentation, the child survived following surgery.