Ann Thorac Surg 2001;72:1364-1366
© 2001 The Society of Thoracic Surgeons
Case report
Suicidal nonfatal impalement injury of the thorax
Anthony J. Cartwright, MB, ChBa,
Karel O. Taams, FCS(SA)a,
M. Jonathan Unsworth-White, FRCS(CTh)a,
Nilofer Mahmood, FRCAa,
Peter M. Murphy, FRCAa
a Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, United Kingdom
Accepted for publication September 25, 2000.
Address reprint requests to Mr Unsworth-White, Department of Cardiothoracics, Derriford Hospital, Plymouth, Devon PL6 8DH, United Kingdom
e-mail: jonathan.unsworthwhite{at}phnt.swest.nhs.uk
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Abstract
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We treated an impalement injury of the thorax resulting from a suicide attempt in the form of a road traffic accident. The patient survived and was discharged 5 weeks after his injury. The surgical management of thoracic impalement injuries and the rationale behind a multidisciplinary approach are discussed.
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Introduction
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Chest injuries are responsible for 25% of trauma deaths in the United Kingdom [1]. Many patients sustaining major intrathoracic injuries die at the scene. Those that survive to hospital admission are therefore a self-selected group with a reasonable chance of survival. Impalement injuries of the thorax requiring surgical intervention are rare and lethal without appropriate treatment. We report a patient who sustained an impalement injury of the thorax and discuss the multidisciplinary approach and trauma protocols.
A 29-year-old man with a depressive and suicidal history was driving when his car left the road at speed, in an act of attempted suicide, went down the bank of the road, through a wooden fence, approximately 200 meters across a field, and into a second wooden fence. A 5 x 10-cm diameter fence post, approximately 1 meter long, pierced the windshield of the car and entered the patient’s right chest just below the clavicle in the midclavicular line (Fig 1A) exiting in the right paravertebral region at the level of the fifth rib (Fig 1B), transfixing him to the driver’s seat. After initial resuscitation at the scene, he was transferred to Derriford Hospital Casualty Department by helicopter with the stake sawn short anteriorly but still in situ. The air ambulance crew took 11 minutes to reach the scene and 26 minutes treating the patient and extricating him from the car. The transport to Derriford Hospital took another 9 minutes. On arrival in the casualty department, his Glasgow Coma Scale was 15, and he was hemodynamically stable. The airway was clear and he was breathing spontaneously on 100% oxygen maintaining saturations of 99%; therefore, a chest drain was not needed at this stage. After further resuscitation and a secondary survey he was transferred directly to cardiothoracic operating theaters.
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Fig 1. Wooden fence post piercing the patient. The post enters the patient’s chest just below the clavicle in the midclavicular line (A) and exits in the right paravertebral region at the level of the fifth rib (B).
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On arrival in the operating room he remained conscious with a Glasgow Coma Scale of 15. Arterial and right internal jugular venous access was obtained, including a pulmonary artery catheter introduced for fluid management, before a rapid sequence induction using a double-lumen endotracheal tube. Throughout this procedure, the patient remained in a left lateral position because of the presence of the fence post. A right posterolateral thoracotomy incision extending to and including the exit wound was made. The stake had entered the right chest through the first intercostal space, fracturing the clavicle and destroying most of the second rib, before transfixing the right upper lobe and exiting through the fourth and fifth intercostal spaces posteriorly. There were bone, wood, glass, and clothing fragments within the chest cavity, with extensive soft tissue injury. The stake was removed under direct vision, and a right upper lobectomy was done. The cavity was copiously irrigated, and one basal and two apical chest drains were placed. The exit wound was debrided, and the thoracotomy was closed in layers. As the patient was placed on his back, extensive hemorrhage issued from the right subclavian vein. This was ligated. The entry wound could not be closed because of tissue loss. It was debrided and packed, and the patient was transferred to the intensive care unit.
The main postoperative concern was infection from the dirty nature of the wound. For this reason he was prescribed broad-spectrum antibiotics, and a major infective episode was avoided.
His rib and right clavicle fractures were treated conservatively; however, reconstructive surgery was required for the large defect of the pectoralis muscle and overlying skin. His right arm became slightly swollen in the first few days postoperatively but it resolved with elevation of the limb. A pectoralis myocutaneous transposition flap from the contralateral side based on the thoracoacromial vessels was tunnelled underneath the skin overlying the sternum. The muscle bulk was used to obliterate the extensive dead space. The skin island of 6 x 8 cm was used to close the remaining skin defect. Postoperatively the patient remained sedated in the intensive care unit for a week after his injury. No wound healing complications occurred. Apart from bronchoscopies to clear mucus plugs from the right main bronchus and a thoracoscopic evacuation of a 500-mL right hemothorax, he had an uneventful recovery and was discharged 5 weeks after admission under the care of psychiatrists.
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Comment
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There are a few reports of similar impalement injuries of the thorax [2–4]. In patients who survive the transit to a casualty department, the reported mortality rate is up to 40% [5]. Injury involving the heart in a similar group of patients had a mortality rate of 68% [6]. If the patient survives the initial insult and appropriate trauma management is instituted, the outcome can be successful. In this case the patient arrived at a major hospital with cardiothoracic facilities in less than 1 hour from the initial insult. The following points regarding the surgical treatment of penetrating thoracic injuries have been noted by ourselves and others [2–4]. The impaled object should be left in situ at the scene. The object can be shortened to facilitate transport of the patient. The impaled object should be removed only in the operating theater under direct vision, to ensure adequate hemostasis. The patient should be transported rapidly to a hospital capable of accepting cardiothoracic trauma. Usual advanced trauma life support guidelines should be followed regarding the initial resuscitation. Preoperative radiologic investigation including a computed tomographic scan of the chest and aortogram can be invaluable in deciding the optimal operative approach, but only if the patient is stable. Although this would be ideal, the patient with extensive penetrating trauma could require surgical intervention with minimal delay. A consultant cardiothoracic anesthetist should be available to anesthetize the patient. Wound debridement and early involvement of reconstructive surgeons will minimize postoperative complications. This case highlights the multidisciplinary approach from the prehospital setting to discharge. Early intervention by separate surgical specialties minimized potentially life-threatening complications and optimized the outcome.
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References
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Rooney S., Westaby S., Graham T. Chest injuries. In: Skinner D., Driscoll P., Earlem R., eds. ABC of major trauma. London: BMJ Publishing Group, 1996:15-21.
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Fradet G., Nelems B., Muller N.L. Penetrating injury of the torso with impalement of the thoracic aorta: pre-operative value of the computed tomographic scan. Ann Thorac Surg 1988;45:680-681.[Abstract/Free Full Text]
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Simokawa S., Shiota K., Ogata S., Toyohira H., Moriyama Y., Taira A. Impalement injury of the thorax: a case report. Surg Today 1994;24:926-928.[Medline]
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Abstract
Introduction
