Penetrating Trauma to the Chest, Abdomen, and Extremities Case

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https://medical-phd.blogspot.com/2021/05/penetrating-trauma-to-chest-abdomen-and.html

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 8
An intoxicated 25-year-old man was brought to the emergency department (ED) by paramedics
after he was involved in an altercation and sustained several stab wounds to the torso and upper
extremities. His initial vital signs in the ED showed pulse rate of 100 beats per minute, blood
pressure of 112/80 mm Hg, respiratory rate of 20 breaths per minute, and Glasgow coma scale of
13. A 2-cm stab wound is noted over the left anterior chest just below the left nipple. Additionally,
there is a 2-cm wound adjacent to the umbilicus, and several 1- to 2-cm stab wounds are noted in
right arm and forearm, near the antecubital fossa. The abdominal and chest wounds are not actively
bleeding and there is no apparent hematoma associated with these wounds. However, one of the
wounds in the right arm is associated with a 10-cm hematoma that is actively oozing. 

⯈ What are the next steps in the evaluation of this patient?

⯈ What are the complications associated with these injuries?

ANSWER TO CASE 8:
Penetrating Trauma to the Chest, Abdomen, and Extremities

Summary: A 25-year-old hemodynamically stable, intoxicated man presents with stab wounds to
the chest, abdomen, and upper extremities.

• Next step: Assess ABCDE: airway, breathing, circulation, disability, and exposure. After
completing this survey, consider probing knife wounds (except chest wounds) to see whether they
are superficial or deep.
• Potential complications from injuries:
    • Chest wound: Pericardial effusion/tamponade, pneumothorax, hemothorax, diaphragmatic
injury
    • Abdominal wound: Hollow viscus, vascular, or urinary tract injury
    • Extremities: Vascular, nerve, or tendon injury

ANALYSIS
Objectives

1. Be able to classify penetrating injuries by location, including chest, thoracoabdominal

region, abdomen, flank, back, and “cardiac box.”
2. Learn the priorities involved in the initial management of penetrating injuries.
3. Become familiar with the treatments of penetrating truncal and extremity injuries.
Considerations
A systematic approach must be undertaken in the evaluation of this patient. The clinician must
guard against being distracted by injuries not immediately threatening to loss of life or
limb. Likewise, young healthy individuals, particularly those who are intoxicated, may have
significant injuries and not manifest many physical examination findings or hemodynamic changes.
Advanced trauma life support (ATLS) guidelines stress the initial primary survey to identify and
address potentially life-threatening injuries. The primary survey consists of the ABCDEs (airway,
breathing, circulation, disability, and exposure). Exposure (removing all of the patient’s clothing
and rolling the patient to examine the patient’s backside) is particularly important in a patient with
penetrating trauma because puncture wounds may be hidden in axillary, inguinal, and gluteal folds.

Following the primary survey, preliminary labs, plain x-rays, and a bedside ultrasound should be
obtained as clinically indicated. In this case, an upright chest x-ray (CXR), preferably at end
expiration will be needed to assess for pneumothorax and hemothorax. A focused abdominal
sonogram for trauma (FAST) examination should be performed to evaluate for pericardial and
intraperitoneal free fluid. This patient is hemodynamically stable and possesses minimal abdominal
examination findings. Therefore, a reasonable strategy is to perform local wound exploration to
determine the depth of the puncture wound. A wound that does not penetrate the abdominal fascia
may be irrigated and closed without further diagnostic requirement. However, it is important to
note that in an intoxicated patient, the physical examination may not be very sensitive.

Approach To:
Penetrating Trauma

DEFINITIONS
CHEST: Area from clavicles to costal margins, 360 degrees around.
“CARDIAC BOX”: Anatomical region bordered by the clavicles superiorly, bilateral
midclavicular lines laterally, and the costal margins inferiorly. This box includes the epigastric
region between the costal margins. Eighty-five percent of penetrating cardiac stab wounds originate
from a puncture to the “box.”
THORACOABDOMINAL: Area from the inframammary crease (women) or nipples (men),
down to the costal margins, 360 degrees around. The clinical significance of a penetrating wound to
this region is that there is a risk of injury to the intrathoracic and intra-abdominal contents, as well
as to the diaphragm.
ANTERIOR ABDOMEN: Area bordered by the costal margins superiorly, the bilateral
midaxillary lines laterally, and by the inguinal ligaments inferiorly.
FLANK: Area from the coastal margin down to the iliac crest, and between the anterior and
posterior axillary lines.
BACK: Area between the posterior axillary lines. Because of thick musculature over the back, only
about 5% of stab wounds to the back lead to significant injuries.

CLINICAL APPROACH
Initial Management
The primary survey, or ABCDEs, should be addressed first (see Table I–2 in Section I). The
clinician should not be distracted by eye-catching but not immediately life-threatening injuries. In
an unstable patient, treatment decisions often need to be made before obtaining diagnostic tests. For
example, a patient with a stab wound to the chest and rapidly dropping oxygen saturations will
require tube thoracostomy (“B” breathing) prior to confirmatory CXR. Bleeding, even if profuse, is
most effectively controlled by direct hand pressure to the bleeding site. Gauze and pressure
dressings are generally less effective. All patients should have immediate placement of large-bore
IV access at two sites. Volume repletion should be initiated with warm IV fluids. After completion
of the primary survey, a systematic search for other injuries (secondary survey) should be
undertaken. Diagnostic tests should be performed expeditiously after the primary survey and often
concurrent with the secondary survey (Table 8–1).
In general, gunshot wounds are more likely to cause greater tissue destruction and life-threatening
injuries than stab wounds. This is due to the unpredictable path of the bullet which can lead to
significant tissue destruction. Hence, it is not safe to assume that a bullet has taken a direct path
between the entrance and exit wounds.