Thoraco- abdominal impalement injury: a case report
© Malla et al.; licensee BioMed Central Ltd. 2014
Received: 24 April 2013
Accepted: 25 February 2014
Published: 4 March 2014
Impalement injury is an uncommon presentation in the emergency department (ED), and penetrating thoraco-abdominal injuries demand immediate life-saving measures and prompt care. Massive penetrating trauma by impalement in a pediatric case represents a particularly challenging presentation for emergency providers in non-trauma center settings.
We report a case of 10 year old male who presented in our ED with an alleged history of fall from an approximately 15 foot tall coconut tree, landing over an upright bamboo stake approximately 50 centimeter long, resulting in a trans-abdomino, trans-thoracic injury. In addition to prompt resuscitation and hospital transfer, assessment of damage to vital structures in conjunction with surgical specialty consultation was an immediate goal.
This article describes a case study of an impalement injury, relevant review of the available literature, and highlights the peculiar strategies required in the setting of a resource limited ED.
KeywordsNepal Trauma Emergency medicine Trauma surgery Rural emergency medicine
The management of impalement injuries poses specific challenges in pre-hospital care and transport. There is uniform agreement that the impaling object should be left in situ until management at a tertiary trauma center can be started [1–6]. Furthermore, targeted examination in the hospital should expedite critical, definitive treatments. We report the successful management of a complex impalement case in a rural emergency setting in Nepal. We discovered that prompt diagnostic and treatment decisions in conjunction with a collaborative trauma team leads to a favorable outcomes in non-trauma care settings.
A 10-year-old boy fell approximately fifteen feet from a coconut tree and landed on a bamboo stake. The stake penetrated the child at the left lower abdomen and exited at zone 1 of the neck resulting in nearly vertical impalement in the caudo-cephaloid direction. Bystanders uprooted the bamboo stake from the ground as gently as possible to prevent movement of the stick within the child’s abdominal and thoracic cavities as instructed by a local health worker on scene. Emergency Medical Services (EMS) personnel in Nepal are only beginning specialized training beyond basic assessment and transfer, so further interventions such fluid resuscitation was not performed on scene or enroute. Further, due to the poor internal infrastructure as a result of financial and political instability in Nepal as well as the native rugged terrain, the transport time was approximately 3 hours.
Ceftriaxone, metronidazole and tetanus vaccination were administered as per ED protocol for emergent surgeries. After the parents’ informed consent, the anesthesia team performed rapid sequence intubation using a double lumen tube for single lung ventilation in the operating theatre. The patient was placed on slight right lateral position to facilitate a left sided thoraco-abdominal surgical approach. Intra-operatively, an approximately 50-cm long bamboo stick penetrating through the anterior abdominal wall at left iliac fossa causing minimal colonic injury (AAST- OIS Grade 1), and transecting jejunum 45 cm from the duodeno-jejunal flexure (AAST- OIS Grade 5) was noted. The bamboo stake further penetrated the body of stomach and passed through the diaphragm.
In the thoracic compartment, the object had transected the left lower lobe of the lung and lacerated the upper left lobe, exiting the body from the posterior triangle of the neck. Incredibly, no major vessels were injured, and the mediastinal organs were intact, except for gross contamination with gastrointestinal contents. The bamboo stake was removed by careful dissection from the injured abdominal organs and the diaphragm as well as adequate proximal and distal vascular control.
The child remained intubated and was transferred to the ICU. Meropenem and clindamycin were added as the ICU team was concerned about contamination from organic matter and hollow viscus injury. These medications were donated free of charge. After extubation at 36 hours, he was transferred to the surgical ward. His postoperative period was complicated by superficial infection of the entry wound on the fourth hospital day, which was managed by local dressings and topical antibiotics. A psychiatric evaluation for post-traumatic stress disorder elicited no psychopathologic disorder. The child was discharged home after 21 days in the hospital and was recovering well on 1-month follow up without neurological or functional deficits.
Principles of management of impalement injury
The pre-hospital providers should leave the impaled object in situ to provide a possible tamponade effect and permit the focus on rapid transport as the goal
The patient should be rapidly stabilized and transported, preferably to a trauma center and
The patient should be rapidly assessed and resuscitated in the emergency department, avoiding any unnecessary tests that delay care, and then transported to the operating room for definitive care.
Care at the scene
Medics should obtain as much information as possible about the impaled object (length, shape, material), mechanism of the injury or any potential for chemical or bacterial contamination to focus adequate first aid measures . Expedient pre-hospital care can be the difference in successful resuscitations, and further medical training for our EMS personnel is an imperative for improvement of trauma care in Nepal.
Emergency department care
A patient with an impalement injury may benefit from timely diagnostic studies to identify internal injuries, the trajectory of the impaled object, and complications of the injury needing urgent attention. Of these imaging modalities, ultrasound imaging is increasingly utilized, as it is a rapid and sensitive diagnostic tool that is available in much of the developing world. Many ED physicians have been trained in its use and utility, unfortunately this has not yet reached our ED. In our case, CT was utilized to expedite effectual surgical planning and execution. Serial clinical assessments of vital signs and mental status as well as ABGs and hematocrits can help reveal physiologic deterioration. The value of simply physically reexamining the patient serially cannot be overemphasized, especially in austere settings. These interventions can help stratify patients, as impalements with stable vital signs tend to have spared vital organs. Another intervention that may improve outcomes is administration of antibiotics. We administered ceftriaxone, metronidazole and tetanus vaccination. The decision of the ICU to further cover with meropenem and clindamycin is not supported by medical literature and reflects an area in which interdepartmental communication can improve patient care.
A rare thoraco -abdominal impalement injury with damage to multiple organs was managed successfully not only because of prompt, coordinated action, but also because child was brought with foreign body in situ. Our case provides insights into how this rare injury pattern can be managed in resource-constrained settings. To summarize, the outcome after massive thoraco-abdominal impalement can be improved in rural, under-resourced settings by (a) rapid transportation with the impaled object in situ (b) targeted, succinct examination and serial reassessments in the emergency department (c) pre-operative and intraoperative antibiotic and decontamination strategies to prevent and manage infections.
Written informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-In -Chief of this journal.
Airway, breathing and circulation
- CT scan:
Computed tomography scan
Primary trauma care
Advanced trauma life support
Beats per minute
Emergency medical services.
The authors are grateful to R.K Rauniyar, MD, Department of Radiology and diagnostics for providing the plain film of the thorax and the abdominal CT scan reports.
- Robicsek F, Daugherty HK, Stansfield AV: Massive chest trauma due to impalement. J Thorac Cardiovasc Surg. 1984, 87: 634-636.PubMedGoogle Scholar
- Chhavi S, D’souza N, Mishra B, Gupta B, Das S: Management of a massive thoracoabdominal impalement: a case report. Scand J Trauma Resusc Emerg Med. 2009, 17: 50-10.1186/1757-7241-17-50.View ArticleGoogle Scholar
- Eder F, Meyer F, Huth C, Halloul Z, Lippert H: Penetrating abdomino-thoracic injuries: report of four impressive, spectacular and representative cases as well as their challenging surgical management. Pol Przegl Chir. 2011, 83: 117-122.PubMedGoogle Scholar
- Abdullahi A, Salahi R, Foroutan A, Banani SA, Abbasi HR, Paydar S, Taheri A, Bolandparvaz S, Foroutan HR: Nonfatal perineal impalement injury traversing pelvic, abdominal, and thoracic cavities. Am Surg. 2011, 77: E232-E235.PubMedGoogle Scholar
- Mohan R, Ram DU, Baba YS, Shetty A, Bhandary S: Transabdominal impalement: absence of visceral or vascular injury a rare possibility. J Emerg Med. 2011, 41: 495-498. 10.1016/j.jemermed.2008.03.033.View ArticlePubMedGoogle Scholar
- Badri F, Al-Mazrouei A, Azam H, Alamri N: Impalement injury – presentation of two new cases. Hamdan Med J. 2012, 5: 173-178.View ArticleGoogle Scholar
- Vaslef SN, Dragelin JB, Takia MW, Saliba EJ: Multiple impalement with survival. Am J Emerg Med. 1997, 15: 70-71. 10.1016/S0735-6757(97)90053-X.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/14/7/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.