Download Case 1205: Penetrating chest Injury Authors and Affiliations

Case 1205: Penetrating chest Injury
Authors and Affiliations
Yushak Abdul Wahab
IMU Clinical School
Seremban
Malaysia
Dr Colin Tso
Cardiologist
Adjunct Senior Lecturer
University of Notre Dame, Sydney
Australia.
This case discusses the management of penetrating chest trauma.
Case Overview
Learning Objectives
With regard to penetrating trauma, the front line doctor at the Emergency Department should be able to:
assess
make
calmly the situation the victim is in and reassure him
a rapid trauma survey
initiate
resuscitation, should it be needed
strategize
the management plan
anticipate
the potential problems during treatment
Question 1 : SC
Question Information:
A 63-year-old man presents to the Emergency Department (ED) after a fall in his home, during which a
ball-point pen in his shirt pocket penetrated his left chest. On arrival at the ED, he is fully conscious with
a blood pressure of 120/70 mmHg and pulse rate of 100/min. These vital signs remain stable. A metallic
pen is noted piercing the left fifth intercostal space just infero-medial to the nipple. The pen pulsates
with each heart-beat. The lungs are clear and air entry is good. The abdomen is soft and non-tender,
with normal bowel sounds.
Question:
Which one of the following is the most appropriate first step in the management?
Choice 1: Establish two peripheral intravenous lines for fluid and blood transfusion, and draw blood for crossmatching Score : 1
Choice Feedback:
One of the first steps in the management of an injured patient is the establishment of a venous access
for infusion of fluid (crystalloids) and/or blood replacement. In this instance, his airway is clear, his
breathing is not compromised and his blood pressure is within normal range.
Choice 2: Insert a chest tube Score : 0
Choice Feedback:
There is no indication for insertion of a chest tube at the moment as there is no evidence of lung
injuries, neither haemo- nor pneumo-thorax. The chest tube can be inserted at the time of removal of
the penetrating object (the pen).
Choice 3: Send the patient immediately for chest radiographs Score : 0
Choice Feedback:
It is helpful to assess the depth of penetration and to look for evidence of lung injuries, but it should be
done following establishment of the intravenous line and if the patient remained haemo-dynamically
stable.
Question 2 : SC
Question Information:
A peripheral venous line is established and blood samples are collected for routine laboratory analysis
and group and save. The chest radiographs, lateral and antero-posterior views, revealed that the pen
has penetrated 4 cm through the chest wall in the fifth intercostal space opposite the left ventricle.
There is no evidence of any pneumothorax or haemo-thorax.
Consideration must now be given to removal of the penetrating object.
Question:
Which one of the following is the most appropriate strategy?
Choice 1: prepare the patient for a possible open heart surgery Score : 1
Choice Feedback:
Whilst probably unnecessary, this approach would be a most sensible move in case the pen had
penetrated the left ventricular wall, even though it may not have entered the ventricular lumen.
Choice 2: omit preparation for possible open heart surgery and proceed with the left anterior thoracotomy Score
:0
Choice Feedback:
This may be acceptable in a setting where the facility for open heart surgery is not available and
transferring the patient to a hospital with such facility is less practical. However, it could be quite difficult
to suture the ventricular wall, if there is a puncture, with the heart still pumping.
Question 3 : SC
Question Information:
At surgery, the pen was observed to have penetrated the pericardial fat pad over the anterior surface of
the left ventricle but had not penetrated the pericardial sac, though it was bruised.
Question:
Which of the following intraoperative steps would be most appropriate?
Choice 1: take a sample of tissue for microbiological culture, lavage the wound and insert a chest tube before
closing the thoracotomy wound Score : 1
Choice Feedback:
Identifying possible contaminants introduced by the penetrating object is a sensible thing to do, and
inserting a drain following a thoracotomy is a standard procedure to avoid leaving residual air causing
an iatrogenic pneumothorax.
Choice 2: close the thoracotomy incision without insertion of a chest tube, but request the anaesthetist to fully
expand the lungs before tightening the last suture Score : 0
Choice Feedback:
The procedure is probably acceptable but there is still a risk of pneumothorax developing after
thoracotomy closure, compromising full re-expansion of the lungs to prevent complications such as
empyema. Why take the risk?
Question 4 : MS
Question Information:
A minithoracotomy is performed and the pericardial sac seen to be bruised, but intact. The pen is
removed The operation goes smoothly and the patient is transferred back to the Intensive Care Unit for
close observation.
Question:
If this patient requires ventilation post-operatively, which of the following steps would prevent posttraumatic pulmonary insufficiency following surgery?
Choice 1: the use of fine, high efficiency filters for blood transfusion Score : 0
Choice Feedback:
It would be judicious in a patient requiring blood transfusion, but not in this patient.
Choice 2: avoidance of excessive intravenous fluid infusion Score : 0
Choice Feedback:
It is probably of less irrelevant in this case as he was never hypotensive at any stage.
Choice 3: the use of volume-controlled respirator Score : 1
Choice Feedback:
Assuming that the peak flow is normal, the respirator would enable the patient to breathe spontaneously
without †˜ working†™, hence he is fully rested on the ventilator, except for triggering
Choice 4: addition to ventilation of positive end-expiratory pressure Score : 1
Choice Feedback:
The step would facilitate full expansion of the lungs thus helping to prevent atelectasis and secondary
lung infections
Choice 5: performance of tracheostomy Score : 0
Choice Feedback:
Prolonged endotracheal intubation especially after one or two weeks is likely to produce various
degrees of laryngeal and tracheal injuries, from inflammation and oedema to stenosis, especially at the
level of the erytenoids. Even perforations of the trachea and oesophagus have been known to occur,
and tracheostomy would reduce the likelihood of these complications but also reduce the respiratory
†˜ dead space†™. In this patient the issue of prolonged ventilation and tracheal intubation did not
arise
Synopsis
The types and severity of injury in penetrating chest trauma depends on the penetrating object or
weapon, commonly bullets and knives. In terms of outcome, gunshot wounds are more likely to be fatal
compared to stab wounds. Early recognition and early treatment are therefore important.
When the chest wall is penetrated, various organs, including the lungs, heart, great vessels, diaphragm,
coronary arteries, oesophagus, liver, spleen and spinal cord, may be injured. The manifestations, in
order of frequency are:
Haemo-pneumothorax
Haemothorax
Pneumothorax
Next to the lungs, the heart is the most frequently injured intra-thoracic structure, with death occurring in
62 to 84% of the victims. The frequency of injury to each cardiac chamber is proportional to the area in
contact with the anterior chest wall; thus the right ventricle is the most commonly involved, followed by
the left ventricle, the right atrium and lastly, the left atrium.
Patients with cardiac injury classically presents in one of two ways:
cardiac
tamponade, or
hypovolemic
shock if the wound communicates with the chest cavity.
The two may occur together, and are difficult to distinguish; however, tamponade is most reliably
diagnosed on the presence of elevated central venous pressure (raised jugular venous pressure), or
when the hypotension is out of proportion to the external injury and external blood loss.
PRINCIPLES OF MANAGEMENT OF PENETRATING CHEST TRAUMA
Management of penetrating chest injury is based on three main measures:
1. intercostal tube drainage (permitting early lung re-expansion), with fluid and blood replacement
2. thoracotomy in patients with massive blood loss and rarely massive air leaks
3. prevention of post-traumatic pulmonary insufficiency
Steps for prevention of post-traumatic pulmonary insufficiency include:
use
of fine high-efficiency blood filters during transfusion
avoidance
of excessive fluid infusion
performance
use
the
of tracheostomy in patients requiring prolonged endotracheal intubation
of volume-assisted ventilation
addition of positive end-expiratory pressure (PEEP) to ventilation
Long Term Sequelae of Penetrating Chest Injuries
Except for early lung complications such as atelectasis, the complications incurred by the survivors are
relatively uncommon.
Special notes on management of penetrating injuries to the heart
It is important to distinguish penetrating injury to the heart from penetration of other intra-thoracic
structures as the treatment greatly differs. Since the mid-sixties, early surgical intervention replaced the
primary reliance on minimally invasive procedure of pericardiocentesis. The change in strategy had
resulted in lower mortalities, and mainly because surgeons are more familiar with thoracotomy which
allows them early control of major haemorrhage and repair of concomitant injuries. Findings at autopsy
of false positive peri-cardiocentesis due clotted blood in the pericardial space had caused delay in
definitive surgical treatment of the deceased. Also, the cardiac wounds found at autopsies were often
repairable.
Reference:
Rourke LL; McKenzie FN; Heimbecker RO: Penetrating Chest wound: a case report. CMA Journal April
1977/Volume 116
June 2015