The management of impalement injury

Abdominal stab wounds with retained knife: 15 years of experience from a major trauma centre in South Africa

INTRODUCTION

This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW).

METHODS

A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW.

RESULTS

A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), p<0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities.

CONCLUSIONS

Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

The Management of Penetrating Neck Injury With Retained Knife: 15-Year Experience From a Major Trauma Center in South Africa

BACKGROUND

This study reviews our cumulative experience with the management of patients presenting with a retained knife following a penetrating neck injury (PNI).

METHODS

A retrospective cohort study was conducted at a major trauma center in South Africa over a 15-year period from July 2006 to December 2020. All patients who presented with a retained knife in the neck following a stab wound (SW) were included.

RESULTS

Twenty-two cases were included: 20 males (91%), mean age: 29 years. 77% (17/22) were retained knives and 23% (5/22) were retained blades. Eighteen (82%) were in the anterior neck, and the remaining 4 cases were in the posterior neck. Plain radiography was performed in 95% (21/22) of cases, and computed tomography (CT) was performed in 91% (20/22). Ninety-five percent (21/22) had the knife or blade extracted in the operating room (OR). Formal neck exploration (FNE) was undertaken in 45% (10/22) of cases, and the remaining 55% (12/22) underwent simple extraction (SE) only. Formal neck exploration was more commonly performed for anterior neck retained knives than the posterior neck, although not statistically significant [56% (10/18) vs 0% (0/18), P = .096]. There were no significant differences in the need for intensive care admission, length of hospital stay, morbidities, or mortalities between anterior and posterior neck retained knives.

DISCUSSION

Uncontrolled extraction of a retained knife in the neck outside of the operating room may be dangerous. Retained knives in the anterior neck commonly required formal neck exploration but not for posterior neck retained knives.

Major penetrating thoracic trauma - The importance of collaboration between different specialties

Introduction

Penetrating thoracic trauma presents a rare and serious condition with great diversity in impalement mechanisms and following injuries, resulting in a high mortality. This case reports successful management of a severe thoracic trauma and need for collaboration between surgical specialties.

Presentation of case

An 18-year-old, otherwise healthy, Caucasian female had penetration of the chest with a wooden post due to a solo car accident and was admitted to a Level 1 trauma center at a university hospital. Trauma computed tomography scan showed costa fractures and fracture of the left clavicular bone. Damage to the subclavian artery, the brachial plexus and pulmonary artery were suspected. Extracorporeal circulation was on standby at surgery. However, removal of the foreign object did not result in any major bleeding. The patient was discharged from hospital on the 19th day after surgery. Fifteen months after the trauma, surgery was performed to remove the first two costae on the left side, as a disfiguring prominence on the neck was the patients' only complaint.

Discussion

Initial management of the patient should follow ATLS® principles with stabilization of airways, breathing and circulation. Multidisciplinary approach resulted in reconstruction of vessels, debridement and wound closure. The importance of follow-up after trauma and surgery are underlined by the current case, as the patient required additional surgery at follow up.

Conclusion

Multidisciplinary approach to the current penetrating trauma resulted in rapid assessment of injuries and management with excellent outcome.

Difficulties in the Management of Impalement Injuries Sustained in Rural India

Impalement injury is said to occur when a blunt force causes a long object to penetrate a body part resulting in retention of the object in situ. We report two unusual cases of impalement from rural India: one, chest impalement by a hunting spear and the other, an extremity impalement by a rotatory tiller blade. Thoracic impalement injuries are very rare, and there is only one other published report of chest impalement by a spear (trident) in the modern era. There are only two published reports of extremity impalement by a rotatory tiller blade. We also describe the difficulties encountered in their management. Patient-1 sustained accidental impalement to the right hemithorax by a spear used for hunting wild boars, leaving a meter long shaft protruding from his body. This necessitated his transfer to the hospital on the cargo bay of a pickup truck and also precluded complete radiological investigations before surgery. In addition, the reversed barbed tip of the spear made the extraction difficult. Patient-2 sustained impalement through the right knee by a rotatory tiller blade which bound him to the machine. The blade had to be disconnected from the shank assembly of the tiller to extricate him. Due to the proximity of the blade to the popliteal vessels, vascular control was necessary before extraction. Both the patients took several hours to reach the hospital as the accident occurred in remote rural areas. However, both had a successful outcome after surgical removal of the impaled object by a multidisciplinary involvement. We also have reviewed the published literature and given our suggestions for the management of these unusual and difficult injuries.

An unusual mechanism of hook impalement injury - A case report

A six-year-old boy was playing at his home, trying to climb up on a metallic gate which was attached with a hooked chain, and suddenly the child slipped down. The hook of the chain, including its ‘U’ shape segment got embedded into the posteromedial aspect of his thigh, through a small entry wound. An anteromedial aspect of the thigh carries a neuro-vascular bundle of the lower limb. To remove the hooked part from muscles near to femoral vessels without damaging them requires surgical skill and consideration for vascular emergencies. At the same time, the procedure is an important step. After resuscitation, the patient is taken into the emergency operation theatre, and the hook was safely removed under vision. In the postoperative period, the child recovered well, and the wound was healthy at the time of discharge.

Two lucky survivors of thoracic impalement in childhood: case report and literature review

BACKGROUND

Penetrating thoracic injuries are uncommon in childhood. Massive penetrating injury due to impalement is even more rare and has scarcely been reported. It has a dramatic clinical presentation and is often fatal, depending on the organs injured.

CASE PRESENTATION

Two boys presented with an unusual mechanism of injury. They fell from a height to be impaled by a large stick. Appropriate emergency medical service was not available and surgery was delayed by more than 24 h after the accident. Both children were labelled "lucky" as they survived the injury without any significant sequelae.

CONCLUSION

We discuss two new cases of pediatric thoracic impalement and perform the first literature review on the subject. Emphasis should be given to the initial care which comprises avoiding premature removal, rapid transport, resuscitation, anti-tetanus and antibiotics. All reported cases had a favorable outcome, even those managed within the constraints of low-income countries.

Sledge Hammer Impalement: a case report of challenges of managing a patient with a heavy pendant

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This patient suffered an impalement injury by falling on the upright handle of a sledge hammer.

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The hammer head was too heavy for patient transport hence patient was fixed to small sized but heavy hammer head.

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Patient had to be moved simultaneously with the sledge hammer.

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We argue that this meets the definition criteria for transfixion injury.

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We propose that transfixion injury be defined in terms of weight of the impaling object relative to the weight of the patient and ability to mobilize the patient and not necessarily by size of the impaling object.

Introduction

Impalement injuries are well defined. Transfixion injuries involve impalement and are defined in terms of fixation usually to a large object.

Case Report

We report a spectacular case of sledge hammer impalement in the neck where the patient was transfixed, albeit to a small object, requiring movement of the patient and the transfixing object as a single unit.

Discussion

The patient was fixed to the head of the sledge hammer because he was unable to move with the heavy pendant.

Conclusion

We argue that transfixion injuries should be defined in terms of weight of the object in relation to the patient‘s weight and the ability of the patient to move (with) the impaling object.

Survival after abdominal impalement with a diver's harpoon

INTRODUCTION

Abdominal impalement by spear is fortunately exceptional. In the literature, only twenty cases have been so far reported. In most cases, transfixing wounds result in serious visceral and/or vascular lesions with a high risk of mortality. Those cases need careful planning and a preoperative order to properly control the spring harpoon during extraction. The extraction of the spear is a delicate process requiring a thorough study of each case to avoid further damage to the patient. This case is written following the SCARE scale for case report writing.

PRESENTATION OF CASE

We report the case of a 39-year patient, admitted to the hospital only after 13 h after the accident. No visceral or vascular lesion was observed, except minimal liver damage to the 3rd liver segment. The liver was almost spared in only the third segment was lightly touched and regarding the vascular and visceral apparatus, no serious lesions were highlighted.

DISCUSSION

The marking problem we encountered with this patient was that the harpoon ended by a mobile spring beard, which led to a profound lesion and also, to a certain difficulty to get access to it. Also, because of the aorta wound, the surgical approach was chosen, allowing a good exposure of the object.

CONCLUSION

When it comes to abdominal impalement, following the rules of transporting and mobilizing the patient, using the infectious risk prevention and knowing the importance of the initial assessment of damage aided by radiology, can allow better management of the situation.

Crowbar impalement: the PHEM perspective

A man in his 50s suffered an impalement on a crowbar after falling from the roof of a domestic shed. A helicopter-based prehospital emergency medical service team was called to assist in the patient's care. The crowbar had entered from the left-upper quadrant and was tenting the skin of the right iliac fossa. Analgesia and prehospital sedation were provided to facilitate extrication. A series of improvisations were carried out to support the logistics of transferring the patient using an air ambulance to the regional major trauma centre with the crowbar in situ. The patient was taken to the operating theatre without any imaging and a section of perforated bowel was removed. He made a full recovery and was discharged home 9 days postincident.

A forensic evaluation of impalement injuries

Impalement injuries transfix a victim in an inescapable or helpless position. A study was undertaken at Forensic Science SA from 2002 to 2016 of all impalement deaths. There were six vehicle accidents (M:F=5:1; age 14-67 years, average age 38.5 years) involving impalements with a tree branch ( n=2; groin and chest), a metal pipe ( n=2; leg and head), a metal bridge railing (groin) and a metal fence post (chest). Two cases (both males, aged 47 and 18 years) had slipped on fences/gates, with impalements of the ankle and groin. A case of suicide (male, aged 80 years) was impaled through the head on a bolt fixed to the floor. A homicide case (male, aged 27 years) involved impalement through the chest by a spear from a spear gun. In certain cases (e.g. with anogenital injuries), differentiating accidental from inflicted impalement injuries may be difficult. In equivocal cases, adequate scene evaluations with photographic documentation are required prior to autopsy, ideally with the object available for examination.

Surgical management of impalement injuries to the trunk of dogs: a multicentre retrospective study

OBJECTIVES

To review a large series of dogs referred for treatment of traumatic impalement injuries to the thorax and/or abdomen and to report aetiologies, injury characteristics, management and long-term outcomes.

MATERIALS AND METHODS

Previously collected data on dogs that were surgically treated for impalement injuries to the trunk at six veterinary specialist referral institutions in the UK over an 11-year period were reviewed. Data included patient signalment, physiological variables, injury-specific variables, diagnostic imaging reports, surgical procedures undertaken, duration of hospitalisation, antibiotic use, complications and outcomes. Data were reported with summary statistics.

RESULTS

Fifty-four dogs were included. Impalement occurred most frequently on wooden objects (n=34), and the thoracic cavity was most commonly penetrated (n=37). Computed tomography was sensitive and specific to identifying wooden material in 64% and 88% of cases (n=11), respectively. Thoracotomy was performed in 56%, coeliotomy in 20% and a foreign body or its fragments were retrieved during surgery in 37% of the cases. Complications occurred in 19 dogs (35%), and of these, 68% were minor and 32% major. The survival rate for thoracotomy cases was 93% (n=30). Overall long-term survival was 90%.

CLINICAL SIGNIFICANCE

Despite the often dramatic presentation of impalement injuries, the majority of patients treated in the specialist referral setting can achieve excellent outcomes. These injuries require thorough diagnostic imaging and interpretation before adequate surgical exploration and management, augmented by anaesthesia and critical care during the peri- and postoperative periods; therefore stable patients should be referred to centres able to provide this type of care.

Management of the retained knife blade

BACKGROUND

The retained knife blade is an unusual and spectacular injury. The aim of this study was to review our experience with the management of such injuries.

METHODS

A retrospective chart review of patients with retained knife blades treated at Groote Schuur Hospital Trauma Centre from January 1996 to December 2007 was undertaken.

RESULTS

Thirty-three patients with retained knife blades were identified. Site of wound entry was the thorax in 13 patients (40%), the neck and back in 7 patients (21%) each, upper and lower extremities in 4 (12%), and the face and abdomen in 1 patient (3%) each. Thirty patients (91%) were hemodynamically stable on admission; two (6%) presented with wound abscesses, and one patient (3%) with active bleeding required emergency surgery. All 33 blades were extracted after clinical and radiological assessment. Simple withdrawal of the blade was possible in 19 cases (58%) and the likelihood of post-extraction bleeding was only 5%. Thirteen patients (40%) required an open surgical approach through dissection of the entry wound, laparotomy, or thoracotomy. Video-assisted thoracoscopic removal was used in one case. Retained thoracic blades were significantly associated with postoperative sepsis (P = 0.0054). There were no deaths.

CONCLUSIONS

All impacted knife injuries require careful clinical and radiological assessment. Simple withdrawal can be performed safely in the emergency room provided potential life-threatening vascular and solid organ injuries have been excluded. There should be a low threshold for investigating and treating patients with retained intrathoracic blades for postoperative sepsis.

Plank fence penetration into automobiles-implications for prevention initiatives

The wooden plank fence presents a deadly but unrecognized hazard to motorists. We hypothesize that fence plank injury is prevalent and results in significant morbidity and mortality. Databases of the University of Kentucky's Level I Trauma Center and the Fayette County Coroner were retrospectively analyzed over a 12-year period (1995-2006). One hundred and twenty-eight subjects were involved in vehicle contact with wooden plank fences. One hundred and twenty-three subjects were evaluated at the Emergency Department of our trauma center; 35 (27%) had a patient-plank interaction (PPI). Men (30/35) were more frequently involved (86%), and average age was 32.8 years. Thirty-two (91%) were drivers; 14/35 (40%) died from PPI-related injuries. The most common cause of death was blunt head trauma in 13 of these 14 fatally injured subjects (93%). This study provides new data underscoring the frequency, lethality, and economic consequences of this injury mechanism. Further research is needed to quantify the national prevalence of this problem and develop injury-mitigating strategies pertaining to roadway or fence design.

Penetrating pediatric trauma owing to improper child safety seat use

We present a case of a 15-month-old child with a history of thoracic impalement after improper safety seat restraint. The foreign body was stabilized with bulky dressings in the field before transport. Imaging revealed possible pulmonary artery involvement; and consequently, a thoracotomy was done to obtain vascular control before removal. We use this case to highlight prehospital care and operative management of a patient with foreign body impalement.

Acute and critical care management of a pediatric patient with medullo-cerebellar impaling

The authors present a child with an accidental cervical medullo-cerebellar impaling by an aluminum rod. Careful planning for safe removal of the rod as well as vigilant attention to early cardiac instability and flash neurogenic pulmonary edema were paramount to her successful recovery. This patient illustrates that it is possible to survive impaling of the brainstem but it requires both innovation and collaboration by multiple specialists across different departments. The value of well coordinated and collaborative neuro surgical intensive care is demonstrated in this young girl's nearly complete recovery from the accident.

Transabdominal impalement: absence of visceral or vascular injury a rare possibility

BACKGROUND

Abdominal impalement injuries are usually associated with visceral and vascular injury, causing significant morbidity and mortality. The management of these injuries poses specific challenges in prehospital care, transport, and management strategies.

OBJECTIVE

We report a case of transabdominal impalement with no injury to intra-abdominal visceral or vascular structures, demonstrating a chance occurrence. The literature regarding abdominal impalement injury is reviewed and the management of these injuries is discussed.

CASE REPORT

A 35-year-old man with a transabdominal impalement injury after an accidental fall from a tree on to a wooden fence was brought to the Accident and Emergency Department. The wooden fence piece was impaled and in situ. Laparotomy revealed no intra-abdominal visceral or vascular injury.

CONCLUSION

Transabdominal impalement injuries pose peculiar challenges in prehospital care, transport to hospital, and management. Operative intervention is required in all cases for a conclusive and safe management, as the possibility of escaping intra-abdominal injury is very rare.

[Removal of a thoracic impaling agent without direct observation. The significance of pre-operative diagnosis]

Impalement injuries are uncommon and only occasional reports exist in the literature, resulting in non standardized approaches. Depending on the location, completely different combinations of injuries occur, making every impalement unique. Nevertheless some basic principles for dealing with impalements exist. These principles, and some controversial statements in the literature on the value of preoperative diagnostics, especially CT, are discussed using the example of a spectacular thoracic impalement by a 2 x 2 cm square metal pole. Our deviation from the principal of removing an impaling object only under direct observation in this special case is also discussed.

Penetrating trauma in children

Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.

Impalement injuries involving the spinal canal

Two cases of impalement injury involving the spinal canal are presented. In the first patient septic bacteria were carried into the spinal canal along the track of the impaling rod. This patient died of sepsis. In the second patient a steel rod penetrated the patient's trunk on the right side, traversing his body obliquely, impaling the L1 vertebral body and coming to lie in the left retroperitoneal space. This injury was not complicated by infection and the patient recovered without any neurological deficit. The principles of managing these injuries and factors influencing their outcomes are discussed.

Pediatric perineal impalement injuries

Pediatric perineal impalement injuries are relatively uncommon. There may be difficulty in recognizing or properly treating such injuries, because their severity may not be reflected accurately by the external appearance of the perineum. The authors describe 3 case reports of patients with perineal impalement injuries and their management. The authors emphasize how a thorough workup can prevent missed injuries, leading to timely surgical repair and good outcomes.

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.