Massive Thoracoabdominal Impalement

**kellyhound** · #1 ● 11-04-2022, 08:53 AM

A 26 year old male was impaled through his chest and upper abdomen with an iron angle, one and half meter long and five centimeters thick. The iron angle entered the chest, through the epigastrium and exited posteriorly just inferior to the angle of left scapula. The patient was transported to hospital with the iron angle in situ. Positioning the patient for intubation proved a major challenge. An unconventional position for intubation allowed a successful airway management.

Paucity of time prevented us from gauging the nature and extent of injury. The challenges posed by massive impalement could be successfully managed due to rapid pre-hospital transfer and co-ordinated team effort.'

Thoracoabdominal impalement injuries are relatively uncommon and only a few cases have been reported in the literature [1–5]. A great deal of force is required to impale thorax and thus there is extensive local tissue destruction with elements of both blunt and penetrating injury.

Management of such cases provides a challenge to anesthetists and surgeons as the extent of injury is unknown and there is inadequate time for evaluation and resuscitation of the patient.

We describe the successful anesthetic management of a major impalement wound of the torso and some principles of management are also highlighted.

A 26 year old male travelling in a car (front seat) at high speed, crashed into a pile of iron angles beside the road at a construction site. One of the iron angles penetrated the windshield and dash-board of the car and impaled his torso. A welder at the construction site was summoned to cut the iron angle. The impaled segment which was one and half meter in length was left undisturbed. Within 30 minutes of the accident, the patient was shifted to the trauma centre.

On arrival, the patient was conscious, oriented but had excruciating pain. The impaled iron angle was projecting in the anterior-posterior direction. It penetrated the epigastrium and exited from the back at the level of the fifth to eight intercostals space, two and half centimeters from the midline just inferior to the left scapula. The patient had pulse rate of 120 beats per minute, blood pressure 110/60 mmHg and his arterial oxygen saturation was 90%. His breathing was rapid and shallow.

The patient and the iron angle were supported at all times to avoid further manipulation. He was transferred directly to the operating room in the sitting position without any investigations (hematological, biochemistry or radiological).

In the operating room he was connected to a multichannel monitor. Two large bore peripheral venous accesses were secured and samples were sent for hematological investigations and blood products were arranged.

Even slight change in the patient position or movement of the rod exaggerated the pain so it was decided to intubate the patient in semi-reclining position supported by helpers. The anesthetist stood on the foot stool to gain additional height.

After counseling the patient, anesthesia was induced with 2 mg/kg ketamine and 1.5 mg/kg suxamethonium.

The trachea was intubated with 8.0 mm cuffed endotracheal tube under direct vision with minimal external laryngeal manipulation.

Bilateral equal air entry was confirmed and the tube position was secured. Right radial artery was cannulated using 20 gauge cannula. The patient was then positioned on the operating table in the right lateral position. Anesthesia was maintained with 60% N20 in oxygen with 0.5-1% isoflurane. Paralysis was maintained with vecuronium and fentanyl 2 mcg/kg was given for analgesia.

Intraoperative electrocardiogram, saturation, blood pressure, end-tidal carbon dioxide (ETCO2), temperature and arterial blood gases were continuously monitored.

After induction of anesthesia, the protruding portion of the rod was cleaned and wrapped in sterile laparoscopic camera covers so that it could be handled in a sterile manner.

A left thoracoabdominal incision was given joining the entry and exit wounds. The damage incurred was a lacerated left lobe of the liver, transected upper half of the spleen, almost 10 cm rupture of the stomach and divided central tendon of the diaphragm.

Posteriorly the diaphragm and the left lung were lacerated before the bar exited the posterior thoracic wall fracturing the 7th, 8th and 9th ribs.

The iron angle was lifted under vision directly from the surgical incision. Surgical procedures performed were splenectomy, gastroraphy, left phrenorraphy and the lung laceration was repaired.

The surgery lasted for three hours. Total blood loss was approximately 1000 ml. Intraoperative arterial blood gas analysis was within normal limits.

Post operatively, a thoracic epidural was inserted at the level of T 11-12 space and continuous infusion was started with 0.125% bupivacaine and 2 mcg/kg fentanyl at the rate 4 ml/hour.

Patient was shifted to the intensive care unit (ICU) for elective ventilation. The trachea was successfully extubated the next morning. The patient was shifted to the ward after 48 hours and discharged from the hospital after 8 days.

No post operative surgical complication, neurological damage or permanent injuries were noted. Presently, the patient is leading a normal life.

Thoracoabdominal impalement is one of the most severe types of penetrating trauma. Such injuries usually involve vital organs, compromising the normal physiology of respiration and circulation.

As in any other trauma scenario, there is a trimodal distribution of death. Early deaths occurring within 30 minutes to 3 hours are secondary to hypoxemia, airway obstruction, hemorrhage, haemothorax, cardiac tamponade and aspiration.

Complications associated with chest trauma include tracheobronchial tree disruption, diaphragmatic tear, oesophageal disruption, myocardial contusion, pulmonary contusion and thoracic aorta rupture.