Presentation of penetrative trauma

Penetrative trauma – presentation and management

Definition of penetrative chest trauma:Penetrative chest trauma is when a an object (usually sharp/bullet) enters the chest causing a small or large entry hole. The object may hit other contents in the chest, affecting the patient’s safety.

Anatomy:
Among the structures that may be damaged are:
1. Thoracic cage (ribs, stenum, manubrium)
2. Mediastinum and the contents(superior, anterior, middle, posterior)
3. Diaphragm

Presentation:
Patients who came in the emergency department with a penetrative chest trauma often seen presented with these conditions:
1. Decreased consciousness
2. Absent/tachy/brady pulse rate
3. Hyper/hypotension BP
4. Tachy/bradypnoea
5. Shortness of breath
6. The chest is not rising normally during inhalation,
7. Blue lips, tongue due to lack of oxygen in blood (cyanosis)

They can be in 3 different presentation: extremis -> unstable (profound shock) -> stable

Among the injury caused by penetrating trauma to the chest:
1. Open pneumothorax: a hole in the chest allows air to enter the pleural space and prevents development of negative intrapleural pressure.
2. Tension pneumothorax: air enter pleural space but cannot leave and trapped. Eventually, the affected lung become compressed and pushed aside along with other structures.
3. Hemothorax: blood accumulated in pleural space due to injury to blood vessels. Leads to tension pneumothorax.
4. Pericardial tamponade: rapid accumulation of blood in the pericardial space which usually filled with small amount of fluid for heart movement.

Management of penetrative chest trauma in emergency department:
1. Investigation: Chest X-ray (all), transesophageal echocardiograms, CT scans and angiography required in complex cases (stable ptx).
2. Pre-hospital management: If the ptx has tension pneumothorax, apply needle thorascopy and administer oxygen mask.
3. Emergency room management:
a. Obtain the x-ray prior to chest tube insertion, except in the case of tension pneumothorax or the ptx is rapidly dying.
b. Estimate the degree of hemothorax/pneumothorax.
c. Identify if there’s any fractured ribs that may indicate arterial bleeding.

4. Emergency room thoracotomy:
a. For ptx with witnessed signs of life. (ptx with cardiac arrest, presence of hemothorax/pneumothorax)
b. Apply cross-clamping to the hilum to control haemorrhaging from lung and prevent further air emboli.

5. Management in the operating room:
a. Indicators for operation due to penetrating chest injuries:
i. Aorta, subclavian or carotid artery injuries.
ii. Hilar injuries.
iii. Bronchus, trachea and oesophagus injuries.
iv. >250ml blood loss/hour for >2 hours.
v. Massive clotting hemothorax.
b. Procedures in operating room:
i. Thoracotomy incision: Anterolateral for unstable ptx on the injury side. Posterolateral for oesophageal(right) and aortic(left) injuries.
ii. Pulmonary tractotomy for lung injuries in unstable ptx.
iii. Thoracoscopy to examine mediastinum, remove blood clot and evaluate diaphragm in stable ptx.