• Clinical science

Penetrating trauma

Summary

Penetrating trauma is an injury caused by a foreign object piercing the skin, which damages the underlying tissues and results in an open wound. The most common causes of such trauma are gunshots and stab wounds. Clinical features differ depending on the injured parts of the body and the shape and size of the penetrating object. Diagnosis is established based on history and imaging studies (X-rays, CT/MRI). Management usually involves supportive measures (hemostasis, blood transfusion, respiratory support), and surgical repair of damaged structures and/or removal of foreign bodies.





General information

Gunshot injuries

  • Mechanisms of injury
    • Medium-velocity or high-velocity injuries
    • Damage also caused to structures adjacent to the path of the bullet
    • Dense organs (e.g., liver, spleen) undergo more damage because they absorb more energy, resulting in greater injury.

Other penetrating injuries

  • Mechanism of injury
    • Usually caused by a sharp, impaling object (e.g., knife, ice pick, broken bottle)
    • Low-velocity injuries
    • Hemorrhage and infection are the most significant mechanisms responsible for morbidity and mortality.

References:[1][2]

Penetrating abdominal trauma

Etiology

Clinical features

Any wound located anteriorly between the nipple line (T4) and the groin creases, and posteriorly between T4 and the curves of the iliac crests is considered a potential penetrating abdominal injury!

Approach to penetrating abdominal trauma

  1. History: details such as number of shots heard, amount of blood loss at the scene of injury, and position of patient when shot or stabbed
  2. Preliminary assessment and care
    • Prehospital and hospital trauma care
    • Resuscitative and stabilization procedures; (e.g., rapid transfusions; , CPR) indicated if the patient is hemodynamically unstable
    • Tetanus prophylaxis
    • Broad spectrum antibiotic prophylaxis
    • Analgesics, anxiolytics
  3. Surgical management
    • Emergency exploratory laparotomy indicated in
      • Evisceration
      • Signs of peritonitis
      • Hemodynamic instability
      • Bleeding detected in nasal tube or rectal examination
      • Penetrating object still in situ (risk of precipitous hemorrhage on removal)
      • Free air under the diaphragm
    • Assess for peritoneal or retroperitoneal penetration and intra-abdominal bleeding
  4. Conservative management
    • Indications: surgical treatment not required
    • Measures
      • Close monitoring of vital signs
      • Serial physical examinations
      • Blood analysis to monitor hemodynamic state

Penetrating trauma below the nipple line (4th intercostal space) essentially involves the abdomen and may require an emergency exploratory laparotomy!

In cases of gunshot wounds, an entry wound in almost any part of the body can result in a penetrating abdominal injury, depending on the path the bullet may have taken through the body. This makes a comprehensive clinical and imaging-based assessment vital!

Patients without evidence of peritonitis, evisceration, and hemodynamic instability may undergo CT prior to surgical intervention!

Penetrating objects often tamponade the wound and should be removed only in a setting where definitive care is possible!

References:[3][4][5][6]

Penetrating chest trauma

Etiology

  • Gunshot wounds
  • Stabbing

Possible injuries

Clinical features

Approach to penetrating chest trauma

  1. Preliminary assessment and care: See “Preliminary assessment and care” in approach to penetrating abdominal trauma above.
  2. Emergency procedures
    • Tube thoracostomy or a needle decompression for tension pneumothorax
    • Placement of an occlusive dressing, taped on three sides, for a sucking chest wound
    • Emergency thoracotomy indicated in
      • Cardiac tamponade
      • Hemodynamically unstable patient
      • Cardiac arrest that occurred at, or after, presentation
      • Unstable patient and/or penetrating object still in-situ
  3. Assessment of injury cause and severity
    • Ultrasound (Extended Focused Assessment with Sonography in Trauma, EFAST)
    • Chest x-ray; and/or CT if patient is stable
    • Others: echocardiography, endoscopy, bronchoscopy, angiography
  4. Further management
    • Close monitoring of vital signs
    • Continual reassessment
    • Appropriate surgical repair after hemodynamic stabilization

Consider concomitant intra-abdominal injuries in cases of injury either below the nipples or the inferior scapular angle!

Penetrating objects should only be removed in the operating room.

References:[7][8]

Other types of penetrating injury

Penetrating neck trauma

  • Etiology:
    • Stab injuries
    • Ballistic injuries
  • Clinical features: features of injuries to the neck can be divided into
  • Approach to penetrating neck trauma
    1. Preliminary assessment and care: See “Preliminary assessment and care” in approach to penetrating abdominal trauma above.
    2. In case of presence of hard signs:
    3. Further management
      • Determine injury extent: CT angiography (best initial test), esophagram, panendoscopy
      • Gunshot wound: conservative or surgical management based on injury extent
      • Stab wounds
        • Patients with no signs of severe vascular or organ injury, can be safely observed

Penetrating trauma to the extremities

  • Etiology:
    • Ballistic injuries (most commonly in a military setting; gunshots, shrapnel, projectiles)
    • Stab injuries (due to sharp objects like knives, vehicular parts in road traffic accidents, rods, etc.)
  • Clinical features: presentation depends on possible underlying injuries
    • Vascular injuries ;:
      • Hard signs of arterial injury include active hemorrhage, expanding or pulsatile hematoma, bruit or thrill over the wound, absent distal pulses, and extremity ischemia.
    • Nerve injuries: loss of sensation or function of the affected limb
    • Skeletomuscular injuries
  • Management:
    • The approach is based on anatomic location and whether major vessel injury is suspected
      • No major vessels in the vicinity of the tract of the penetrating object: conservative management
      • Stable patients with a penetration tract in the vicinity of major vessels and local signs (pain/tenderness), but no systemic signs of hypovolemia, should undergo further diagnostic testing:
        • Plain x-ray; : evaluate extent of bony injury
        • Contrast CT angiography: evaluate vascular injury
        • Doppler ultrasonographic evaluation: evaluate vascular injury in cases with poor renal function, in which contrast CT is contraindicated
      • Patients exhibiting 'hard signs' of arterial injury: urgent surgical exploration, hemorrhage control, and repair
      • In case of combined injury to arteries, nerves and bones: start with stabilization of bone (fracture reduction etc.) → vascular repairnerve repair

References:[9][10][11][12][13][14][15]

Diaphragmatic rupture

  • Etiology: penetrating injuries (65%), blunt trauma (35%)
  • Clinical features
    • Often initially asymptomatic
    • Chest/abdominal wall bruises
    • In case of herniation of abdominal organs into the chest
      • Decreased breath sounds; , bowel sounds in the thorax, respiratory distress
      • Signs of bowel obstruction
  • Diagnostics
    • Chest x-ray
      • Disturbed contour of the hemidiaphragm
      • Displaced abdominal organs; (esp. stomach and bowel segments): hourglass sign
      • Possible mediastinal shift
      • Nasogastric tube visible above the left hemidiaphragm
    • Ultrasound FAST: rapidly detect large tears or herniation
    • CT scan to confirm the diagnosis
  • Complications: diaphragm paralysis
  • Treatment: most patients require surgery

References:[16][17][18][19]

Hemothorax

A hemothorax, however small, must always be drained because blood in the pleural cavity will clot if not evacuated, resulting in a trapped lung or an empyema

References:[20][21][22][23][24]