European Journal of Cardiovascular Medicine

Impalement injuries to the thorax are life-threatening, particularly when they penetrate the cardiac box—the area within the thoracic outlet, xiphisternum, and midclavicular lines. These injuries can result from various incidents, including stab wounds, road accidents involving construction materials, or falls onto sharp objects. Such injuries require timely and expert intervention to improve survival outcomes.

The clinical presentation of thoracic impalement injuries varies based on the injury's location and the organs impaled. Penetration of the airway, lung, or both can cause chest pain and shortness of breath, typically due to pneumothorax or hemothorax. Hemodynamic stability in these patients depends on the volume of blood loss and whether a tension pneumothorax is present. Thoracic surgeons and emergency care specialists should be adept at swiftly diagnosing and managing these life-threatening conditions.

Cardiac impalement injuries, although rare, are often fatal at the scene. Patients who reach trauma centers or emergency departments with such injuries constitute about 0.1% of admissions [1]. Immediate diagnosis and treatment are crucial. Advances in modern medicine have significantly improved the management of these injuries. Techniques such as emergency thoracotomy, the use of cardiopulmonary bypass, and damage control surgery have been pivotal in increasing survival rates for patients with penetrating cardiac injuries [2].

Recent studies have highlighted the importance of a multidisciplinary approach in managing thoracic impalement injuries. This includes the coordination between trauma surgeons, cardiothoracic surgeons, anesthesiologists, and critical care teams to ensure optimal patient outcomes [3]. Additionally, advances in imaging technology, such as high-resolution CT scans, have enhanced the ability to promptly and accurately assess the extent of injuries, facilitating more precise surgical interventions [4].

Historically, cardiac injuries were deemed untreatable, with Boerhaeve in the 18th century claiming all such injuries were fatal. Billroth notably remarked, "The surgeon who should attempt to suture a wound of the heart should lose the respect of his colleagues" [5]. However, advancements in medical science have made surgical intervention a viable option for treating penetrating heart injuries in the 20th century.

The following case series discusses four patients with thoracic impalement injuries, each presenting unique challenges and requiring swift, coordinated medical responses to improve their outcomes.

CASE 1.

An 18-year-old male presented with impalement injury of thorax by iron rods used for construction of building. He was going on a motor cycle and he hit a truck from back side. The truck was loaded with iron rods used for construction and these iron rods were protruding out from the truck. After the accident two iron rods went through and through his right chest. People gathered around at the site of accident and called a blacksmith to cut the iron rods which had penetrated through his chest. Iron rods had gone up to 1 foot behind his back. And on front side they were cut at about 2 feet distance from his chest. Fig. 1

Fig. Patient with iron rods going through and through his right side of chest

The patient arrived at the trauma center within 2 hours, hemodynamically stable with BP 110/70 mm Hg, pulse 110 bpm, and O2 saturation 98%. Chest X-ray and CT scan were performed.

In the Cardiac OT, femoral artery and veins were prepped for any need of possible cardiopulmonary bypass if there could be exsanguinated haemorrhage. Exploratory thoracotomy showed rods penetrating right lung lobes without pulmonary vessel injury. Lung injuries were stapled, avoiding pneumonectomy. Haemostasis and air leaks were checked, a chest drain was placed, and the chest was closed. The patient was extubated and moved to ICU in stable condition.

Post-op chest X-ray showed normal lung fields, and he was doing well during one year of follow up. Fig. 2 to Fig. 7.

Fig. 2 Chext Xray AP view showing iron rods on right side of chest

Fig. 3 Chest X ray lateral view showing iron rods through and through the chest

Fig.4 Right Common Femoral Artery and Vein Cannulated

Fig. 5 One of the iron rods going through the right lung seen after thoracotomy

Fig. 6 Injury caused by iron rod seen after removal of iron rod

Fig. 7 Injury caused in lung by lower iron rod

CASE 2.

A 26-year-old male presented with history of physical assault with sharp object, resulting in penetrating injury to the chest. The foreign body, the knife got stuck in the chest and could not be pulled back by assaulter. In the attempt to pull back the knife, the handle of the knife broke from the knife blade and the blade of the knife remained stuck in the chest.

Patient was taken to nearest civil hospital first and was referred to our trauma center immediately. He reached our trauma center after about 6 hours of assault. On presentation he was stable. His hemodynamic condition was stable. Immediate chest x-ray, ECG, CT thorax and USG chest were done.  ECG was normal. Chest x-ray showed the foreign body stuck in chest. On CT chest and USG mild pneumomediastinum was present.  An urgent call was sent to cardiothoracic  surgery department. We examined the patient and shifted the patient to operating room.

Patient was put on ventilation with Double lumen endotracheal tube. Right anterolateral thoracotomy was done. Knife was going through fourth costo-chondral junction. It was penetrating through the medial segment of the right middle lobe and then pericardium. The knife was removed. Pericardium was opened further. There was clotted and fresh blood present in the pericardium. Blood clots were removed and an injury caused by a knife was found in the right atrium (RA). However, due to clot formation around the knife there was not excessive bleeding from the right atrium. Clots present in RA around the injury site were squeezed out until free flow of blood from RA started. Injured site in RA was clamped with non-traumatic Cooley’s clamp. The injury in RA was sutured with 5-0 polypropylene below the clamp with vertical mattress sutures and after the first layer the clamp was removed and the whole tear in RA was run over with the second layer of 5-0 polypropylene. There was no bleeding from RA.

The injured small portion of the right lung was repaired with linear cutter stapler. The right pleural drain was put in and chest closed. Patient was extubated in the OT and shifted to ICU in stable hemodynamic condition. He did not require any inotropes and there was no bleeding post operatively. The plural drain was removed on the 2nd post-operative day. Patient made uneventful recovery and was discharged on 5^th post-operative day. Fig. 8 to Fig. 11 and doing well on follow-up.

Fig.8. Blade of knife stuck in chest at presentation

Fig. 9. Blade of knife stuck in chest  from side view at presentation

Fig. 10 Chest Xray PA view showing blade of knife stuck in chest

Fig. 11 Chest X ray lateral view showing blade of knife stuck in chest

CASE 3.

A 25-year-old man arrived at trauma centre with an 8mm diameter sharp iron rod impaling his left clavicle. The patient,  had been assaulted with an iron rod used for breaking large ice slabs during a dispute with coworkers. Initially treated at a local hospital, he was referred to us.

Upon arrival three hours post-assault, the patient was stable with a blood pressure of 118/82 mmHg, pulse rate of 88 bpm, and oxygen saturation of 98% on room air. He experienced pain and shortness of breath but no external bleeding. Chest X-ray and CT scans revealed the rod traversing the left clavicle without pneumothorax, projecting into the manubrium sterni.

The cardiothoracic surgical team was consulted for rod removal in the operating room. Blood typing and cross-matching were completed. Under general anaesthesia, preparations for possible massive haemorrhage were made. Orthopaedic surgeon extracted the rod using a drill machine; no bleeding occurred, and the patient remained stable. An intraoperative echocardiogram confirmed the absence of bleeding.

Post-operative chest X-ray showed no abnormalities, and the patient recovered well. He was discharged on the fourth post-operative day in stable condition.

CASE 4.

A 3-year-old boy fell from his roof onto an iron gate with protruding rods. Fig. 12.

Fig. 12 Site of Fall showing roof and projecting iron rods of gate

One rod impaled his lower neck. Initially treated at a nearby hospital, he was swiftly transferred to our trauma centre.

Upon arrival, he was hemodynamically stable but had a respiratory rate of 32/min, heart rate of 150 bpm, and O2 saturation of 94%. He had a deep, 1 cm x 1 cm penetrating neck wound above the sternal notch, with air leak and subcutaneous emphysema spreading from the bilateral supraclavicular regions to the thyroid cartilage. Air bubbles were visible emerging from the injury. Fig. 13.

Fig. 13 Picture of child at presentation showing air bubble coming out of injury site

NCCT scans revealed a linear defect in the lower trachea above the carina, subcutaneous emphysema, pneumomediastinum, minimal left pneumothorax, and pleural effusion.

Referred to cardiothoracic surgery, the patient underwent urgent surgery under general anaesthesia. The neck wound was extended, and strap muscles separated. Positive pressure ventilation exposed an anterolateral tracheal tear covering about two-thirds of the tracheal circumference, approximately 1 cm above the carina. Fig. 14.

Fig. 14. Rent in trachea showing inflated bulb of endotracheal tube inside

The tracheal tear was repaired with 4-0 PDS interrupted sutures, stopping the air leak. Fig. 15.

Fig. 15 Trachea after repair of rent

The pericardium was inspected due to NCCT indications of pneumomediastinum. A drain was placed in the left pleural space, haemostasis ensured, and the sternum closed with stainless steel wires. The patient was extubated in the OT and moved to ICU in stable condition.

Thoracic impalement injuries from stab wounds are more common than gunshot injuries and can damage intrathoracic great vessels [5]. A chest stab wound's clinical presentation can range from no injury to severe life-threatening damage. TTE can help exclude pericardial effusion but may yield false-negatives, as noted by Senanayake et al. [6]. CT scans aid in planning and identifying the injury location [7]. Hemoptysis may indicate PA injury [8]. Delayed cardiac tamponade has been reported after initial negative findings [9]. Thus, maintain a high suspicion for injury in any thoracic penetrating trauma case.

Hydes Commandments for managing impalement injuries remain pertinent, offering invaluable guidelines for effective treatment. When encountering such injuries, it is imperative not to remove the impaled object in the field; instead, immobilize it and swiftly transport the patient to a trauma center. Bleeding should be controlled by applying direct pressure around the impaled object, rather than on it. A vigilant approach is necessary to maintain a high index of suspicion for potential damage to adjacent structures and organs. Imaging studies should be utilized judiciously to accurately assess the extent of injury. Careful planning of the surgical approach is essential, often involving multiple specialties as required. Advanced airway management should be ensured, along with preparedness for massive transfusion protocols. Post-operative care must include diligent monitoring for delayed complications and infections to ensure optimal recovery [10].

For patients with massive haemothorax or significant blood loss, prepare for emergency bypass. CPB prevents blood loss and aids in repairing injuries to the aorta, PA, or cardiac chambers. Rapid hemodynamic decline can lead to cardiac arrest. Initial resuscitation may falsely reassure. Injury type, initial hypotension, metabolic acidosis, chest X-ray, and CT thorax scan indicate urgent surgical exploration.

Median sternotomy enables the establishment of CPB, HCA, and cardioplegic arrest, providing optimal access for repairing injuries to the aortic arch and PA if present [6]. If the patient remains hemodynamically unstable after resuscitation and develops cardiac arrest, an emergency room bilateral anterior thoracotomy should be performed [11]. Exposure and cannulation of femoral vessels may also be conducted before thoracotomy or sternotomy to initiate emergency CPB in cases of extensive bleeding after opening the chest [12]. Accurate interpretation of CT scans can aid in determining the appropriate operative strategy.

A single penetrating thoracic injury can cause significant damage to major vessels, heart chambers, or airways, potentially leading to fatal outcomes. Despite initial cardiovascular stability and negative early tests, intrathoracic injury should still be suspected. This warrants further investigation and timely surgical exploration if necessary.

Impalement injuries to the thorax following stab wounds are more common than gunshot injuries and have the potential to damage intrathoracic great vessels. Stab wounds to the chest can result in a wide range of clinical presentations, from no intrathoracic injury to extensive life-threatening damage to great vessels or the heart.

Hydes Commandments for managing impalement injuries remain pertinent, offering invaluable guidelines for effective treatment. When encountering such injuries, it is imperative not to remove the impaled object in the field; instead, immobilize it and swiftly transport the patient to a trauma center. Bleeding should be controlled by applying direct pressure around the impaled object, rather than on it. A vigilant approach is necessary to maintain a high index of suspicion for potential damage to adjacent structures and organs. Imaging studies should be utilized judiciously to accurately assess the extent of injury. Careful planning of the surgical approach is essential, often involving multiple specialties as required. Advanced airway management should be ensured, along with preparedness for massive transfusion protocols. Post-operative care must include diligent monitoring for delayed complications and infections to ensure optimal recovery.

Transthoracic echocardiography (TTE) can be useful for excluding pericardial effusion, although it may also yield false-negative results, as reported by Senanayake et al. Negative findings should not be misleading, particularly in cases involving penetrating trauma to the cardiac box. CT scans can assist in operative planning and provide information on the location of the injury. Hemoptysis in the patient could indicate pulmonary artery (PA) injury. Reports exist of delayed cardiac tamponade following initial negative investigations; hence, a high index of suspicion for injury should be maintained in any patient with a penetrating thoracic injury (Lohchab et al., IJTCVS).

In patients with massive hemothorax or significant blood loss, preparations for emergency bypass should be made. The use of cardiopulmonary bypass (CPB) prevents further blood loss and facilitates repair if there is an injury to the aorta, PA, or cardiac chambers. Rapid decline in hemodynamic stability, potentially resulting in cardiac arrest, may occur in such patients. Initial resuscitation that results in reasonable clinical status can be falsely reassuring. Indicators for urgent surgical exploration include the nature of the injury, initial hypotensive presentation, metabolic acidosis, chest X-ray findings, and initial CT thorax scan results.

A median sternotomy allows for the establishment of CPB, hypothermic circulatory arrest (HCA), and cardioplegic arrest, providing optimal access for repairing injuries to the aortic arch and PA if present. If a patient remains hemodynamically unstable after resuscitation and experiences cardiac arrest, bilateral anterior thoracotomy in the emergency room should be performed. Exposure and cannulation of femoral vessels may also be conducted before thoracotomy or sternotomy to enable emergency CPB in case of extensive bleeding after opening the chest. Correct interpretation of CT scans may aid in determining the appropriate operative strategy.

Even a single penetrating injury to thorax can cause extensive intrathoracic damage to the great vessels, cardiac chambers and or air ways and can lead to fatal outcomes. A high index of suspicion for intrathoracic injury should remain despite initial cardiovascular stability and early negative investigative findings. This suspicion should prompt further investigations and early surgical exploration as required.

1. Kang, N., et al. "Penetrating Cardiac Injury: Addressing the Challenges." Injury, vol. 40, no. 9, Sept. 2009, pp. 919–927. doi:10.1016/j.injury.2008.12.008.
2. Wani, L., et al. "Penetrating Cardiac Injury: A Review." Trauma Monthly, vol. 17, no. 1, 2012, pp. 230–232.
3. Bargoud, C. G., et al. "Case Report on a Delayed Presentation of a Pneumatic Nail Gun Injury to the Right Ventricle Without Circulatory Compromise." Trauma Case Reports, vol. 37, 23 Dec. 2021, p. 100597. doi:10.1016/j.tcr.2021.100597.
4. Isaza-Restrepo, A., et al. "Penetrating Cardiac Trauma: Analysis of 240 Cases from a Hospital in Bogota, Colombia." World Journal of Emergency Surgery, vol. 12, 12 June 2017, p. 26. doi:10.1186/s13017-017-0144-9.
5. Fulton, J. O., et al. "Penetrating Intrathoracic Great Vessel Injuries." South African Journal of Surgery, vol. 35, no. 2, 1997, pp. 82–86.
6. Senanayake, E. L., et al. "Stab to the Chest Causing Severe Great Vessel Injury." Annals of Thoracic Surgery, vol. 94, 2012, pp. 1716–1718.
7. Pereira, S. J., and J. A. Narrod. "Repair of Right Pulmonary Artery Transection After Blunt Trauma." Annals of Thoracic Surgery, vol. 87, 2009, pp. 939–940.
8. Deneuville, M. "Pulmonary Artery and Branch Injuries from Penetrating Chest Trauma." Annals of Vascular Surgery, vol. 14, 2000, pp. 463–467.
9. Mechem, C. C., and G. A. Alam. "Delayed Cardiac Tamponade in a Patient with Penetrating Chest Trauma." Journal of Emergency Medicine, vol. 15, 1997, pp. 31–33.
10. Hyde, M. R., et al. "Impalement Injuries to the Thorax as a Result of Motor Vehicle Accidents." Annals of Thoracic Surgery, vol. 43, 1987, pp. 189–190.
11. Hunt, P. A., I. Greaves, and W. A. Owens. "Emergency Thoracotomy in Thoracic Trauma—a Review." Injury, vol. 37, 2006, pp. 1–19.
12. Lohchab, S. S., et al. "Impalement Injuries of the Left Thorax, Abdomen and Axilla by Reinforced Iron Rods—A Case Report." Indian Journal of Thoracic and Cardiovascular Surgery, vol. 31, 2015, pp. 260–262.