Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 440-443  

Penetrating chest injury: A miraculous life salvage


Department of General Surgery, Government Medical College, Miraj, Maharashtra, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Santosh B Dalavi
376/1, Wing D/I, Siddivinayakpuram, Dnyaneshwar Chowk, Dattanagar, Sangli - 416 416, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118279

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  Abstract 

An unusual penetrating chest injury was caused by high velocity road traffic accident. An 18-year-old had a four wheeler accident and was brought in emergency department with a 'bamboo' stick on the left side chest exiting through back. After the stabilization of vital parameters, an inter-costal tube drainage was done on the left side.
Except the minor brochopleural fistula which healed by 10 th day, his recovery was uneventful. The outcome was consistent with current aggressive management of penetrating chest injuries. Management of penetrating chest injury involving pulmonary trauma is based on three principles. One is stabilization of hemodynamics of patient with proper clinical evaluation. Second, a mere intercostal tube drainage sufficient for majority of the cases. Third, post-operative active as well as passive physiotherapy is necessary for speedy recovery.

Keywords: Bamboo, chest injury, intercostal drain, penetrating


How to cite this article:
Dalavi SB, Gurav PD, Sharad SS. Penetrating chest injury: A miraculous life salvage. Med J DY Patil Univ 2013;6:440-3

How to cite this URL:
Dalavi SB, Gurav PD, Sharad SS. Penetrating chest injury: A miraculous life salvage. Med J DY Patil Univ [serial online] 2013 [cited 2019 Jan 16];6:440-3. Available from: http://www.mjdrdypu.org/text.asp?2013/6/4/440/118279


  Introduction Top


Thoracic injuries are common, with up to one of five patients presenting with trauma involving the chest. Given the fact that the chest contains the most vital cardiopulmonary structures, these injuries have the potential of being severe. Chest injuries were reported as early as 3000 BC in the Edwin Smith Surgical Papyrus. [1] Galen, one of the most prominent physician of antiquity, described packing of chest wounds in gladiators with thoracic injuries. [2] Presence of heart and great vessels increases mortality of penetrating injury to left side chest up to 25%.

In this case, the patient came with a bamboo stick penetrated through the left side of chest. The bamboo entered through left supraclavicular fossa exiting through 9 th intercostal space posteriorly. The accident place was at approximately 50 km away from the hospital and he was brought to the hospital with bamboo stick in situ. His appearance resembled that of a wounded ancient warrior with spear in the chest [Figure 1] and [Figure 2].
Figure 1: Bamboo stick exiting through left side 9th intercostal space

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Figure 2: CT scan showing foreign body (bamboo) in left apical lobe.

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Miraculously, he reached alive to the hospital in this situation. In literature, there might be a number of cases of penetrating chest injury, but this case is unique because of his willingness to survive.


  Case Report Top


An 18-year-old was brought to the hospital with history of road traffic accident which occurred about 50 km away. He was driving a car at high speed which rammed into a bamboo house. He was brought to hospital with 5 feet long and 2 inches broad bamboo stick in left side of chest [Figure 1] and [Figure 2]. He was drowsy and pale due to severe blood loss. Respiratory rate was 30 per minute; BP was 90/60 mm of Hg. On examination, it was found that the air entry to the left side of chest was absent. Bamboo entered through left supraclavicular fossa above lateral half of clavicle and exited from 9 th intercostal space posteriorly 5 cm from midline. There was a minimal air leak from the exit of wound posteriorly.

His blood sample was sent for blood grouping, cross-matching and other blood profile. Two large bored I.V. cannulas were inserted and crystalloid was given to maintain BP. Foley's catheter was inserted for urine output measurement and blood transfusion was started.

It was decided to put an inter-costal drainage (ICD) tube on the left side. The bamboo stick provided hindrance to the ICD tube but we struggled and finally succeeded to insert a 32 number Romson's chest tube drain on 6 th inter-costal space at mid-axillary line. About 600 cc of blood gushed with air into the ICD bag. It was decided to shorten the bamboo stick from both sides, leaving margin to pull it out later. It also allowed us to adjust the position of patient in CT scan machine. CT scan was done to observe the position of bamboo through lung parenchyma and vital structures like pericardium and great vessels [Figure 3]. CT scans showed presence of hemo-pneumothorax and the bamboo had pierced apical lobe without any injury to the major vessel. We decided to prepare the patient for thoracotomy to remove bamboo from chest. After adequate exposure from anterior wound, we pulled the bamboo stick with controlled traction from anterior aspect. Immediately, we did anterior thoracotomy to expose apical lobe of left side and secured air leak and hemostasis. Patient was kept on ventilator for 24 h post-operatively and extubated later. The post-operative recovery was good except minor bronchopleural fistula, which healed spontaneously on 8 th post-operative day. Patient was discharged on 10 th post-operative day after removal of ICD.
Figure 3: Lateral view CT scan showing path of bamboo through lung parenchyma

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  Discussion Top


Even in the ancient era, most of the therapeutic modalities for chest wounds and traumatic pulmonary injuries were developed during wartime, especially by Ambroise Paré, [3] John Hunter, [3] and Jean-Dominique Larrey. [3]

The liberal use of thoracocentesis in the management of hemothorax, the creation of Mobile Army Surgical Hospital (MASH) units and early evacuation from the combat zone directly to well-organized trauma centers operated under strict resuscitative protocols during World War II, and the Korean and Vietnam conflicts, have contributed to lower the mortality. [4],[5] Tube thoracostomy remains the cornerstone for the treatment of traumatic injuries to the lung. [6]

Recent progress in treating severe pulmonary injuries has relied on finding shorter and simpler lung-sparing techniques. [4],[7] The applicability of stapled pulmonary tractotomy was confirmed as a safe and valuable procedure, [8],[9] and the lung-sparing techniques are associated with an improved morbidity and mortality. [10]

Advancement in technology have revolutionized thoracic surgery and ushered in the era of video-assisted thoracoscopic surgery (VATS), providing an alternative method for accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries, with the advantage of allowing definitive treatment of such injuries. [11] VATS also has been demonstrated to be a reliable operative therapy for complications, including post-traumatic pleural collections. [12]

The clinical presentation of patients sustaining penetrating pulmonary injuries ranges from hemodynamic stability to cardiopulmonary arrest. [13] Patients with penetrating pulmonary injuries may present with symptoms and signs of pneumohemothorax or an open pneumothorax with a partial loss of the chest wall, or may also present with a tension pneumothorax. [13],[14] In our case, presentation is open pneumothorax as air leak is there through exit wound. Patients with penetrating pulmonary injuries may rarely present with a pneumomediastinum upon auscultation. Hamman's Crunch - a systolic crunch - may be detected upon auscultation in these patients. Similarly, they may also present with a pneumopericardium detected by auscultating Brichiteau's windmill bruit (bruit de moulin). Patients with penetrating pulmonary injuries may rarely present with true hemoptysis, and sometimes with symptoms and signs of associated cardiac injuries. [13],[15],[16]

The Focused Assessment Sonogram for Trauma (FAST), chest x-ray PA view, CT scan are non-invasive diagnostic modalities for such cases. Tube thoracostomy-Chest tube placement may be diagnostic as well as therapeutic. [6] It will serve to evacuate air, evacuate and quantify blood, detect massive air leaks, and establish an indication for thoracotomy. [17],[18]

Video-Assisted Thoracoscopic Surgery (VATS)

VATS has provided the trauma surgeon with an alternative method for the accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries, [19],[20] with the advantage of simultaneously allowing definitive treatment of such injuries. VATS also has been demonstrated to be an accurate, safe, and reliable operative therapy for complications of lung trauma, including post-traumatic pleural collections.

The left anterolateral thoracotomy (Spangaro's incision) is the incision of choice for the management of patients with penetrating pulmonary or cardiac injuries who arrive "in extremis". In our case, we used this incision to expose injured lobe. This is the incision of choice in a patient who is hemodynamically unstable owing to injuries that have traversed the mediastinum or one who has sustained associated abdominal injuries. It allows full exposure of the anterior mediastinum and pericardium and both hemithoracic cavities. [21],[22],[23] Other incisions are the posterolateral thoracotomy, and median sternotomy each has its own advantage and disadvantage.

The high mortality rates reported for lobectomy and pneumonectomy when performed after traumatic lung injuries has served to develop less extensive resection techniques. [4],[7],[8],[9],[10],[24] These techniques have been denominated as 'lung-sparing techniques', and include suture pneumonorrhaphy, stapled and clamp pulmonary tractotomy with selective vessel ligation, and non-anatomic resection. These procedures are indicated for control of hemorrhage, control of small air leaks, to preserve pulmonary tissue, and/or when the pulmonary injury is amenable to reconstruction. It is estimated that approximately 85% of all penetrating pulmonary injuries can be managed with these techniques. [3],[8],[9],[10],[11] Resectional procedure like formal lobectomy, pneumonectomy is sparingly used in extreme conditions because of high mortality.

Mortality

The estimated mortality for these procedures is very variable. The overall mortality rate reported in the literature for patients with traumatic pulmonary injuries ranges from 1.7% to 37%. For stapled procedures, the mortality is 10%, for non-anatomic resections is 20%, for lobectomies, it can range from 30% to 50%, and for pneumonectomies, the mortality rate is between 50% and 100%. [4],[8],[10],[24]


  Conclusion Top


Pulmonary injuries requiring thoracotomy are uncommon even in busy urban trauma centers. Simpler surgical techniques are frequently used for their management. Stapled pulmonary tractotomy has become the most frequently used lung-sparing technique and can manage 85% of all pulmonary injuries requiring surgical interventions. Despite recent advances, pulmonary injuries requiring respective procedures are marked by high morbidity and mortality.

 
  References Top

1.Breasted JH, editor. The Edwin Smith Surgical Papyrus. Vol. 1. Chicago, IL: University of Chicago Press; 1930. p. 369-73.  Back to cited text no. 1
    
2.Homer The Iliad. Translated by Alexander Pope. London: George Bell and Sons; 1904. p. 16 299-lines 588-625.  Back to cited text no. 2
    
3.Bellamy RF, Zajtchuk R. The evolution of wound ballistics: A brief history. In: Bellamy RF, Zajtchuk R, editors. Textbook of Military Medicine, Office of the General Surgeon. Department of the Army. Washington, DC; 1989. p. 83-106.  Back to cited text no. 3
    
4.Wall MJ Jr, Hirshberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Am J Surg 1994;168:665-9.  Back to cited text no. 4
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5.Fallon WF. Surgical lessons learned on the battlefield. J Trauma 1997;43:209-13.  Back to cited text no. 5
    
6.Mattox KL, Allen MK. Systematic approach to pneumothorax, hemothorax, pneumomediatinum and subcutaneous emphysema. Injury 1986;17:309-12.  Back to cited text no. 6
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7.Asensio JA, Demetriades D, Berne JD, Velmahos G, Cornwell EE 3 rd , Murray J, et al. Stapled pulmonary tractotomy: A rapid way to control hemorrhage in penetrating pulmonary injuries. J Am Coll Surg 1997;185:486-7.  Back to cited text no. 7
    
8.Velmahos GC, Baker C, Demetriades D, Goodman J, Murray JA, Asensio JA. Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy. Arch Surg 1999;134:186-9.  Back to cited text no. 8
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10.Cothren C, Moore EE, Biffl WL. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma 2002;53:483-7.  Back to cited text no. 10
    
11.Manlulu AV, Lee TW, Thung KH, Wong R, Yim AP. Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries. Eur J Cardiothorac Surg 2004;25:1048-53.  Back to cited text no. 11
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12.Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained post-traumatic hemothorax. Ann Thorac Surg 2004;78:282-6.  Back to cited text no. 12
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16.Pezzella AT, Adebonojo SA, Hooker SG, Mabogunje OA, Conlan AA. et al. Complications in general thoracic surgery. Curr Probl Surg 2000;37:733-860.  Back to cited text no. 16
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17.Cornwell EE 3rd, Kennedy F, Ayad IA, Berne TV, Velmahos G, Asensio J, et al. Transmediastinal gunshot wounds. A reconsideration of the role of aortography. Arch Surg 1996;131:949-52.  Back to cited text no. 17
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18.Hanpeter DE, Demetriades D, Asensio JA, Berne TV, Velmahos G, Murray J. et al. Helical computed tomography scan in the evaluation of mediastinal gunshot wounds. J Trauma 2000;49:689-95.  Back to cited text no. 18
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20.Petrone P, Leppäniemi A, Inaba K, Søreide K, Asensio JA. Diaphragmatic injuries: Challenges in the diagnosis and management. Trauma 2007;9:227-36.   Back to cited text no. 20
    
21.Asensio JA, Stewart BM, Murray J, Fox AH, Falabella A, Gomez H, et al. Penetrating cardiac injuries. Surg Clin North Am 1996;76:685-724.  Back to cited text no. 21
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22.Asensio JA, Murray J, Demetriades D, Berne J, Cornwell E, Velmahos G, et al. Penetrating cardiac injuries: A prospective study of variables predicting outcomes. J Am Coll Surg 1998;186:24-34.  Back to cited text no. 22
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23.Asensio JA, Berne JD, Demetriades D, Chan L, Murray J, Falabella A, et al. One hundred five penetrating cardiac injuries. A two year prospective evaluation. J Trauma 1998;44:1073-82.  Back to cited text no. 23
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24.Huh J, Wall MJ Jr, Estrera AL, Soltero ER, Mattox KL. Surgical management of traumatic pulmonary injury. Am J Surg 2003;186:620-4.  Back to cited text no. 24
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  [Figure 1], [Figure 2], [Figure 3]



 

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