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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 32-34

Impalement injury to chest due to bamboo stick


1 Department of Trauma Surgery and Critical Care, Medaz Hospital, Patna, Bihar, India
2 Department of General Surgery, Medaz Hospital, Patna, Bihar, India
3 Department of Anaesthesiology and Critical Care, IGIMS, Patna, Bihar, India
4 Department of Critical Care, Medaz Hospital, Patna, Bihar, India

Date of Web Publication22-Dec-2021

Correspondence Address:
Majid Anwer
Medaz Hospital, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_15_21

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  Abstract 


Impalement injuries are rare. We present here a case of impalement injury of chest and its management. A 10-year-old boy fell from a tree and landed on pointed bamboo object. He was diagnosed as a case of impalement injury with right-sided pneumothorax. A right anterolateral thoracotomy with removal of foreign body and repair of lung laceration was done. The patient in the postoperative period remained stable. He was discharged on day 10. Thoracic impalement injuries are dangerous injuries because of close proximity of the impaled objects to the heart and major vessel. The impaled object should be left as such and an urgent transfer to a facility dealing with such type of injury is required. A thoracotomy incision based on the tract should be employed. Postoperative patient should be put on broad-spectrum antibiotic along with chest physiotherapy.

Keywords: Anterolateral thoracotomy, impalement injury, lung laceration


How to cite this article:
Anwer M, Uddin MM, Ahmed F, Ur Rahman MA. Impalement injury to chest due to bamboo stick. J Cardiothorac Trauma 2021;6:32-4

How to cite this URL:
Anwer M, Uddin MM, Ahmed F, Ur Rahman MA. Impalement injury to chest due to bamboo stick. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Aug 18];6:32-4. Available from: https://www.jctt.org/text.asp?2021/6/1/32/333274




  Introduction Top


Impalement injuries of chest are rare injuries.[1] We present here a case of impalement injury to chest in a young boy after falling from a tree and landing on a pointed bamboo stick. We describe here the successful management of the patient to discharge.


  Case Report Top


A 10-year-old boy fell from tree and landed on pointed bamboo object [Figure 1]. The patient was primarily treated at a local hospital where a computed tomography (CT) thorax was done, and then, he was brought to our hospital after a gap of 20 h. On evaluation, he was anxious, tachypneic with respiratory rate 30/min, blood pressure 100/60, pulse 130/min, febrile with temp 99.7°F. On chest auscultation, left-sided air entry was normal, however, the right-sided air entry was decreased. On detailed secondary survey, there were 3 open wound, one with foreign object lying in 5th intercostal space (ICS) in midclavicular line, 2 punctured wound one in 6th ICS and one in 10th ICS in posterior axillary line. There was also multiple punctured wound on right mid-thigh on lateral, anterior, medial, and posterior aspect of mid-thigh with no active bleeding. CT thorax was suggestive of a foreign body lodged just above the pericardium along with right-sided pneumothorax with partial collapse of right lung [Figure 2] and [Figure 3]. Few areas of ground-glass attenuation in the apical segment of right upper lobe were noted representing pulmonary hemorrhage or contusion. Furthermore, multifocal areas of ground-glass attenuation and mixed consolidation with cavitation were found in the right lower lobe most likely representing lung contusion and laceration. Pneumomediastinum was also noted. CT angiogram of right lower limb was normal. An echocardiogram showed normal ejection fraction with no pericardial effusion. His blood parameters showed Hb – 8.1, TLC – 17.57, platelet count – 113k, PT/INR = 38.3/3.05, COVID negative. He was transfused 1 PRBC and 4 FFP. He was planned for an urgent operative intervention. He was intubated using single lumen tube. The patient was placed in right lateral decubitus position, and right 5th anterolateral thoracotomy reaching up to the impalement site was done. Around 500 ml of serosanguinous fluid was aspirated. On careful inspection, a foreign body was seen penetrating apical segment of right upper lobe and lodged just above the pericardium pointing upward and tip placed just below the major vessel [Figure 4]. The foreign body was carefully retrieved in Toto [Figure 5] and the tract was looked for any bleeding.
Figure 1: The preoperative picture of the patient

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Figure 2: Showing right-sided large pneumothorax along with laceration of right lower lobe (arrow)

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Figure 3: Showing impaled object passing below the right superior lobe and above the pericardium (arrow)

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Figure 4: Intraoperative image showing removal of foreign body under vision

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Figure 5: Showing retrieved foreign body

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There was no bleeding from the site of impalement. A laceration was also found in the right lower lobe in anterior and posterior location. The lacerated segment was washed with saline and repaired using polypropylene 3-0. Two implantable cardioverter-defibrillators were placed one anterior and one posterior to the lung. The margins of the impaled site were debrided and the thoracotomy incisions were closed in layers primarily. The right thigh wound was washed and dressed. The patient was extubated and kept in the ICU. He was able to maintain saturation on 2 liters of oxygen. A postoperative chest X-ray showed complete lung expansion [Figure 6].
Figure 6: X-ray of chest showing complete expansion of the lung with intercostal drain in place

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He was started on incentive spirometry and chest physiotherapy. On the 1st postoperative day, intercostal drain output was nil in anterior and 100 ml serosanguinous in posterior. The anterior intercostal tube was removed on postoperative day 2 and posterior chest tube was removed on postoperative day 4. The patient was discharged on postoperative day 10. He is in regular follow-up and doing well.


  Discussion Top


Thoracic impalement injuries are rare type of injuries and very few survive to discharge.[1],[2],[3],[4],[5],[6],[7] Thoracic impalement injuries are dangerous injuries because of close proximity of the impaled objects to the heart and major vessel. The management proceeds according to Advanced Trauma Life Support protocol with airway protection with cervical spine immobilization. Any hemo or pneumothorax should be managed with intercostal tube drainage. Do not ever try to pull the impaled object! as removal of foreign body leads to dislodgment of clots and bleeding.[1],[3],[5],[6] An urgent referral to a center dedicated for treating such type of complicated thoracic injury is required. A contrast-enhanced computed tomography thorax will delineate the tract of the impalement object and injuries occurring on the pathway. It will also help in choosing the appropriate thoracic incision. A closed coordination with anesthetist is required for the type of endotracheal tube. The patient can be intubated under double-lumen tube or with single lumen tube. The extended anterolateral or posterolateral thoracotomy approach is employed considering the tract of the impaled object. Under visualization, the impaled object is carefully removed keeping everything ready. The lung laceration should be debrided and repaired using polypropylene. An intercostal tube should be put for postoperative drainage of collection. The wound should be closed primarily after debridement of dead and devitalized tissue.[1]

Postoperatively patient should be put on broad-spectrum antibiotic. The possibility of fungal infection should be kept in mind considering the nature of foreign body. Massive transfusion protocol and the needs for cardiopulmonary bypass should be in hand before undertaking such patients for surgery. The intercostal tube drain should be removed once there is complete expansion of lung and the drainage output has turned serous. Chest physiotherapy with incentive spirometry is to be followed in the postoperative periods.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Romero LH, Nagamia HF, Lefemine AA, Foster ED, Wysocki JP, Berger RL. Massive impalement wound of the chest. A case report. J Thorac Cardiovasc Surg 1978;75:832-5.  Back to cited text no. 1
    
2.
Wood AE. Transfixion injury of the chest. J Trauma 1982;22:432-3.  Back to cited text no. 2
    
3.
Shimokawa S, Shiota K, Ogata S, Toyohira H, Moriyama Y, Taira A. Impalement injury of the thorax: Report of a case. Surg Today 1994;24:926-8.  Back to cited text no. 3
    
4.
Foot CL, Naidoo P. Breaking the rules: A thoracic impalement injury. Med J Aust 1999;171:676-7.  Back to cited text no. 4
    
5.
Shikata H, Tsuchishima S, Sakamoto S, Nagayoshi Y, Shono S, Nishizawa H, et al. Recovery of an impalement and transfixion chest injury by a reinforced steel bar. Ann Thorac Cardiovasc Surg 2001;7:304-6.  Back to cited text no. 5
    
6.
Darbari A, Tandon S, Singh AK. Thoracic impalement injuries. Indian J Thorac Cardiovasc Surg 2005;21:229-31.  Back to cited text no. 6
    
7.
Edwin F, Tettey M, Aniteye L, Kotei D, Tamatey M, Entsuamensah K, et al. Impalement injuries of the chest. Ghana medical journal 2009;43.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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