Breaking the rules: a thoracic impalement injury In the case of a patient with an impalement injury, the object should be
removed in a controlled operating theatre environment. We report an
18-year-old man for whom this rule could not be followed. He was
removed from a metal pipe transfixing his chest at the roadside.
Carole L Foot and Pat Naidoo
MJA 1999; 171: 676-677
| ||
|
→ Other articles have cited this article Introduction -
Clinical record -
Discussion -
References -
Authors' details
| ||
| Introduction | Impalement injuries, in which a large foreign body traverses a body cavity or extremity, produce a dramatic clinical picture. The most important principle of management is that the impaling object should remain in situ while the patient is rapidly transported to an operating theatre, as it can have a tamponade-like effect on damaged vascular structures. We describe the case of an 18-year-old man for whom this rule could not be followed. | ||
| Clinical record | |||
|
An 18-year-old man was a front-seat passenger in a high-speed motor
vehicle accident in which the vehicle ran off the road and struck a
fence. A 4 cm diameter pipe from the fence pierced the windscreen and
transfixed the left anterolateral side of the patient's chest wall,
penetrated the front seat, and finally entered the back-seat
compartment, where it pierced a "jerry can" containing petrol (Figure 1).
When we arrived at the accident scene, the patient had a patent airway and was tachypnoeic, with a respiratory rate of 36 breaths per minute; auscultation revealed normal breath sounds on the right side and diminished breath sounds on the left side of the chest. He was pale, with a pulse rate of 100 beats per minute and palpable blood pressure of 110 mmHg systolic. The heart was visible pulsating through the entry wound, with adjacent collapsed lung also exposed. The patient was alert and complained of severe pain. Oxygen was provided by face mask, cervical spine control was maintained with a hard collar, and two 16-gauge intravenous cannulas were secured. Further examination revealed no other obvious injuries. Cutting instruments used for extrication have a very low risk of causing sparks. However, experienced rescue workers have sometimes noted sparks to arise from "metal on metal" shearing forces created as the entrapping materials are being cut. A fire officer revealed that for this reason the rescue service was extremely hesitant to use their equipment, as there was a fuel leak close to the patient. Therefore, it was decided to remove the patient from the pipe at the accident scene. The procedure was explained to the patient, 10 mg of morphine was given intravenously, and nitrous oxide was administered by demand valve. This combination of analgesia was selected on the basis of its availability and ease of administration, and appeared to be adequate. An incision was made connecting the entry and exit sites and carried down to the pipe; several ribs were already fractured at this site. The patient was then slipped from under the pipe, pressure was applied to the wound (Figure 2), and the patient was transported to a nearby hospital. We spent a total of 25 minutes at the scene. Less than 500 mL of normal saline was administered before arrival at the hospital (according to recommendations of minimal volume resuscitation for penetrating torso trauma).1 On arrival at the hospital, the patient was assessed by a trauma team including a senior anaesthetist and a senior surgeon with experience treating trauma. The patient was in pain, with a respiratory rate of 30 breaths per minute, pulse rate of 92 beats per minute and blood pressure of 150/70 mmHg. A supine chest radiogram showed a clear right lung field and multiple rib fractures on the left side, with a collapsed left lung. At the request of the anaesthetist, and in the event that a small unidentified right pneumothorax was present, an intercostal catheter was rapidly inserted into the right side of the chest as a precaution before commencing positive pressure ventilation. A rapid-sequence induction using thiopentone and suxamethonium was followed by endotracheal intubation. A nasogastric tube and indwelling urinary catheter were inserted. The patient was given an intramuscular injection of adult diphtheria and tetanus toxoid and 1 g of intravenous cephalothin. The trauma team contemplated transporting the patient to the nearest hospital with cardiac bypass facilities (about 30 minutes away by road), but, after examining the wound, the treating surgeon decided to take the patient to theatre locally. In theatre, a small segment of the lingular lobe, damaged soft tissue, and two ribs were excised. The wounds and thoracic cavity were irrigated, followed by primary closure. The patient was admitted to the intensive care unit after surgery, but he required a splenectomy on the following day for a persistently bleeding splenic laceration. The patient was discharged home 15 days after admission. On review 10 days after discharge, his wounds had fully healed, and he had a relatively normal chest radiogram. Figure 3 shows the wound eight months after the accident. | |||
| Discussion | |||
|
Reports of major impalement injuries involving most parts of the body
have been published,2-10 and the concepts that
each impalement is an anatomically distinct injury, that
coincident, more life threatening injuries should not be missed, and
that the cardinal rule of management is "leave the impaling object
in situ" have been well described. In our case, the patient
survived despite our breaking this rule. In a safer setting,
shortening of the pipe in front of and behind the patient using cutting
tools, then transporting the patient to hospital to remove the pipe,
would have been preferable. We could find only one other report of
survival after removal of an impaling object in an uncontrolled
environment -- a reference to an 1812 description of "Thomas Tipple",
who removed himself from an object that had traversed a portion of the
left side of his chest.9
This case is notable by virtue of its dramatic, uncommon nature and unconventional mode of extrication. It is beyond the scope of this article to comment on topics such as controversies in fluid resuscitation and penetrating trauma, the ongoing debate of "field stabilisation" versus a "scoop and run" approach for on-scene trauma management, or airway management and analgesia/anaesthesia options for entrapped patients. Although evidence-based medicine is appropriately becoming the foundation of clinical practice, it is important to remember that "rules" can be broken if you have no choice. | |||
| References | |||
| |||
| Authors' details | |||
|
Carole L Foot, MB BS (Hons, Qld), Emergency Medicine Registrar; Pat Naidoo, MICGP, FACTM, Director of Emergency Medicine.
Reprints will not be available from the authors. ©MJA 1999 Other articles have cited this article:
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> ª 1999 Medical Journal of Australia. We appreciate your comments. | |||
1: The motor vehicle with the pipe which impaled the front-seat passenger.
2a: The patient's wound after removal from the pipe -- anterior view.
2b: The patient's wound after removal from the pipe -- posterior view.
3: The healed wound eight months after the accident.
| |||
Wolfgang Lederer, Hans C Jeske and Kroesen Gunnar. Underestimated damage from multiple impalement injury Med J Aust 2002; 177 (3): 155. [Snapshot] 
