case report penetrating thoracoabdominal injuries from an
TRANSCRIPT
IAR Journal of Medical Case Reports ISSN Print : 2709-3220 | ISSN Online : 2709-3239 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iarjmcr
Available: https://iarconsortium.org/journal-info/iarjmcr 27
Penetrating Thoracoabdominal Injuries from an Iron Fence: Case Report and Literature Review
Abstract: Penetrating injuries through the abdomen and thorax have a higher
impact on morbidity and mortality than injuries inside one of them. Resuscitation
and Handling properly in early stages will bring good results to the patient.
Keywords: injuries, thoracotomy, laparotomy, penetrating, iron fence, thorax-
abdominal, liver.
INTRODUCTION Penetrating injuries through the abdomen and thorax have a higher
impact on morbidity and mortality than injuries inside one of them.
Foreign objects that enter the body cavities should not be detached prior
the patient’s arrival in the operating room (Muchuweti, D., & Muguti, E.
2020). Trauma is the third most prevalent cause of mortality after
cardiovascular disease and cancer and the leading cause of mortality in
patients under 40 years old (Petrowsky, H. et al., 2012). Injury of the
abdomen is an usual cause of death, accounting for 7-10% of trauma
patients. The condition will depend on injured organs and hemodynamic
stability (Johnson, J. J. et al., 2013). Presentation of penetrating
abdominal and chest trauma can provide clinical features of
pneumohemothorax, hemothorax, cardiac tamponade, pneumothorax,
airway obstruction, and pulmonary contusion (Shanmuganathan, K., &
Matsumoto, J. 2006).
Penetrating abdominal injuries can be extended to the intrathoracic
organ, which may present with massive hemoperitoneum due to the
mesentery injury, gaster, spleen, liver, or peritonitis from bowel
perforations. Abdominal stab wounds usually affect hollow viscus organs
(Biffl, W. L., & Moore, E. E. 2010). Foreign bodies that stab intra-
abdominal or chest have a tampon effect, and attempts to remove them
before surgery increase the severity and risk of death. (McDonald, A. A.
et al., 2018).
A total of 1359 patients from 2004 study with traumatic injury of the chest at a United States level I trauma center
figured that only 18% of patients needed tube thoracostomy and 2.6% required advanced thoracotomy (Shanmuganathan,
K., & Matsumoto, J. 2006). The severe injury cases happened from blunt trauma, and the overall death was 9.45%.
Immediate thoracotomy and laparotomy are essential for managing double cavity injuries and retrieving foreign materials
(DeBarros, M., & Martin, M. J. 2015).
ILLUSTRATION
Four hours before admission to the hospital, while a 24 years old Mr. H was repairing the roof of the house by
climbing over the fence, the patient suddenly lost his balance and then slipped from the roof. The patient fell with his
chest position of the lower right abdomen stuck at the end of the open gate in a standing position. The others were
released by lifting the patient's body from the bottom up. After being released from the entrance, one end of the fence
was broken and allegedly left inside the patient's body. After the incident, the patient complained of abdominal and chest
pain. The patient was immediately taken to Sukoharjo District Hospital by rescue workers, put on IV lines, stitched up
the wound, injected with analgetic, and did a chest X-ray. Parts of the iron fence were left in the stomach and chest.
Because of this condition, the patient must get an assessment and intervention of the thoracic and digestive in Dr.
Moewardi Surakarta Hospital.
Case Report
Article History
Received: 20.07.2021
Revision: 31.07.2021
Accepted: 10.08.2021
Published: 20.08.2021
Author Details Imam Hafidh Zaini*1, Pigur Agus Marwanto1,
Agus Raharjo2 and Arif Prasetyo Utomo3
Authors Affiliations 1General Surgery Resident Faculty of
Medicine, Sebelas Maret University, Indonesia 2Digestive Division, Surgery Department,
Faculty of Medicine, Sebelas Maret
University, Indonesia 3Thoracic and Cardiovascular Division,
Surgery Department, Faculty of Medicine,
Sebelas Maret University, Indonesia
Corresponding Author* Imam Hafidh Zaini
How to Cite the Article: Imam Hafidh Zaini, Pigur Agus Marwanto,
Agus Raharjo, & Arif Prasetyo Utomo.
(2021); Penetrating Thoracoabdominal
Injuries from an Iron Fence: Case Report and
Literature Review. IAR J Med Cse Rep. 2(4),
27-33.
Copyright @ 2021: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited.
DOI: 10.47310/iarjmcr.2021.v02i04.007
Imam Hafidh Zaini, et al., IAR J Med Cse Rep; Vol-2, Iss- 4 (July-Aug, 2021): 27-33
28
The patient was a healthy young male with stable
hemodynamic. No sign of anemia and cyanosis in
mucous membranes were found. His blood pressure was
130/80 mmHg, pulse was 108 beats per minute, and
respiratory rate was 28 breaths per minute. Oxygen
saturation level on free air was 94%. Chest examination
showed breathing from the left chest was higher than
the right one. The laceration was sutured with 3.0
nonabsorbable multifilament thread at midaxillary line
sixth intercostal and abdominal above the right inguinal
line. Physical examination revealed lacerations in the
chest and lower right abdomen. On percussion, lung
sounds dim at the level of 5-8 ribs.
(a) (b)
Figure 1. Picture of patient in the emergency room before operating surgery (a) front view and (b) right side view
The patient was given oxygen 10 liters per minute
with a non-rebreathing mask, ringer lactate infusion,
human tetanus immunoglobulin injection 250 UI, and
ampicillin injection 1 g every 8 hours. Breathing
clearance with chest tube placement on the right chest
was performed, produced 300 ml of blood. Before
entering the operation room, the blood production rate
was 200 ml per hour. A nasogastric tube (NGT) was
inserted to drained the bleeding and removed
exaggerated gas from the intra-abdominal cavity. A
transurethral catheter was placed for urine output
measurement. Complete blood count, blood glucose,
FAST, X-ray of the thorax and abdomen were done.
Laboratory results showed low hemoglobin level (9.5
g/dL), elevated white blood cells (18.2 × 103Cells/L),
segmental neutrophil 88.7%, and elevated liver enzyme
(SGOT 391 U/L). The blood gas analysis found pH:
7.565, BE: 3.6 mmol/L, PO2:76.6 mmHg, and lactate
serum increased to 2.5 mmol/L. Minimal hemorrhage in
Morrison pouch was found during FAST examination.
There was also probe tenderness in the epigastric and
the right hypochondriacal to the right lumbar region. X-
ray examination showed that a foreign body penetrating
the lungs and damage to organs in the abdomen couldn't
be evaluated. We managed the case with open surgery.
(A) (B)
Figure 2. Chest x-ray before and after chest tube insertion
Thoracotomy and laparotomy were done
simultaneously with caution on the emergency area that
must be managed first. The foreign object, the green
iron fence, damaged the right pleura and penetrated the
diaphragm. The patient laid in the left lateral decubitus
position and was sedated with general anesthesia. The
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operation began with an aseptic procedure, and then a
15 cm long incision was made on the 6th
ICS at the
posterolateral region, deepened to the intercostal
muscle. The incision was made above the right sixth
rib, anterior to the midaxillary line. Serratus anterior
muscle was preserved by cutting the fascia on the
posterior side. Elevation of the scapula was performed.
The sixth ICS was identified by palpating the ribs under
the scapula (the second ribs at the most prominent part).
One lung procedure was completed and the right lung
was deflated. Dissection above the seventh rib was
performed, opened the parietal pleura. A blood clot was
discovered in the pleural cavity. The foreign object
went through the medial side of the diaphragm with the
tip attached to the pericardium. It was pushed towards
the diaphragm. The diaphragm perforation (diameter 2
cm) was repaired with a simple interrupted 4.0
nonabsorbable monofilament thread. Chest tube
thoracotomy no.28 was inserted into the pleural cavity,
then connected to a single bottle WSD. The production
of WSD was 300 ml of blood from the right pleural
cavity, which was suction out. The chest tube fixated
with lived knots.
Figure 3. Exploratory Thoracotomy procedure followed by insertion of a chest tube
Laparotomy was done in a supine position under
general anesthesia. Midline incision 2 cm below the
xiphoid process of the sternum was made, followed by
dissecting along 20 cm the abdominal wall layer by
layer until the peritoneum was found. The ripped from
the peritoneum was 3 cm as high as the 12th
ribs. The
stomach, spleen, jejunum, ileum, and colon were
identified in good condition. Blood clots and bleeding
were found under the liver, and then the evacuation
procedure was performed. Green iron fierce was
penetrated the liver in VIII zones. Extraction of the
foreign material was carried out, obtained metal with a
conical shape, 15 cm of length and 5 cm of diameter.
Hepatic rupture grade IV was found, and the bleeding
was controlled using a pringle maneuver for the time
being. The liver was pressed with gauze. After 15
minutes of evaluation, the edge of the torn liver was
covered with an absorbable collagen sponge. The
operator washed the abdominal cavity, prepared a
drainage tube, and sutured the peritoneum and fascia. A
peritoneal tube was installed in the right abdomen equal
to the umbilical. Continues suture was performed at the
peritoneum and fascia with multifilament
nonabsorbable thread no 1. The subcutis was sutured
with simple interrupted using 2.0 multifilament
absorbable thread. Then the cutis was stitched with a
simple interrupted using 3.0 nonabsorbable
multifilament suture.
The wound in the right inguinal from the previous
hospital was opened. There is an irregular edge,
subcutis base, 10cm long, contaminants (+) iron rust +
peeling paint wound. Debridement was conducted using
H2O2 and betadine then washed with 0.9% NaCl infuse
until clean. The subcutis was closed with a simple
interrupted 2.0 multifilament absorbable thread. At the
last step, the cutis was done with a simple interrupted
3.0 nonabsorbable multifilament suture. Four bags of
packed red cells and four bags of whole blood were
fulfilled during the operation due to active bleeding.
The total estimated blood loss from the procedure was
800 ml.
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Figure 4. Laparotomy exploration procedure followed by foreign body disposal and insert abdominal tube drainage
Postoperative routine hematology was carried out,
resulting in abnormal leukocytes (15.1 x 103). Chest
imaging demonstrated a lung contusion. The patient
was admitted to the ICU for recovery. Vital signs, urine
output, routine blood laboratory, drainage product from
both chest and abdomen tube measured every day. On
the first day, the chest and abdominal drainage
produced 50 ml and 200 ml sero-hemorrhage. After one
day of treatment in the ICU, leukocytes measurement
came back with normal value. On the third day
postoperative, the drainage production was stopped
from the chest drainage, while the drain from the
abdominal tube still produced 400 ml of bile.
The patient went to the standard care room. A PA
chest X-ray was conducted before the transfer to the
standard care room. The result showed a pulmonary
contusion, and then the chest drainage was removed.
The patient was discharged after seven days of
hospitalization. The abdominal drainage was persisted
with an average production of 50 ml per 24 hours. The
liver function enzymes were elevated (SGOT 104 and
SGPT 143). On the 12th day after the operation, a
follow-up was carried out with the patient's general
condition was good, the wound was clean, and there
were no signs of inflammation. Because the abdominal
drainage was not producing any secrete, it was
removed. Abdominal ultrasound was performed, which
resulted in a normal abdomen. The routine blood and
liver function test were back to the normal level.
DISCUSSION Penetrating trauma in the thorax-abdominal region
may lead to complicated and life-threatening conditions
(Shanmuganathan, K., & Matsumoto, J. 2006). Several
causes, such as high kinetic energy with large-caliber
firearms and low kinetic energy of stab wounds, can
result in penetrating injuries. Patients with stabbing
abdominal trauma should be evaluate signs of organ
failure, pneumothorax, and peritonitis based on physical
examination, laboratory, and radiology, including
ultrasound, CT scan, MRI, or X-rays (Hanna, W. C., &
Ferri, L. E. 2009).
Airway, breathing, and circulation disorders that
require immediate treatment can occur due to
penetrating trauma in the thorax-abdominal region.
Massive hemothorax or penetrating thoracic trauma in
poor condition should undergo resuscitative
thoracotomy (Sawhney, C. et al., 2009). Initial
radiology examinations such as an x-ray of the chest
and focused abdominal sonographic examination for
trauma (FAST) may discover the accumulation of the
blood, both in the abdominal and peritoneal cavity, also
in the pericardial sac (Petrowsky, H. et al., 2012; &
Kim, K. T., & Seo, P. W. 2016). Insertion of a tube into
the pleural cavity to drain air, blood, bile, pus, or other
fluids is called tube thoracostomy. Thoracostomy or
thoracoscopic procedure is indicated when the
mediastinum blood clot evacuation and hemorrhage
control are not achieved. Thoracotomy is indicated
when a large volume of bleeding (>1.500 mL) or
continued hemorrhage (>200 mL/hour) is present
(Chen, C. Y. et al., 2010; Troxler, Max. 2016; & Biffl,
W. L., & Moore, E. E. 2010).
From this case, we found that the patient had
shortness of breath caused by a hematothorax on the
right side with ongoing bleeding. A negative FAST
examination showed no damage, but a green iron fence
on the abdominal wall that penetrated the lung
diaphragm was shown on the x-ray findings. Following
the guidelines from the 2014 World Journal of Surgery,
the examination was continued with thoracoscopy
(Thiam, O. et al., 2016). If there is a rupture of the
diaphragm, then a thoracostomy should be performed,
followed by a laparotomy.
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Figure 5. Concept of thoracoabdominal stab wounds treatment based on initial examination (Biffl, W. L., & Moore, E. E. 2010).
Urgent thoracotomy is needed in the emergency of
hemothorax. Emergency management should consider
many factors, including indications, clinical conditions,
trauma mechanism, and imaging findings. The
requirement for urgent thoracotomy was made based on
ATLS protocol (chest drainage product >1500 ml initial
or >200 ml/day, large un-evacuated clotted hemothorax
which can cause shortness of breath that leads to life-
threatening conditions and risk for cardiac tamponade,
massive air leak, incomplete lung expansion, significant
chest wall defect, injury of the major vessel,
esophageal, diaphragm, and cardiac (Mahoozi, H. R. et
al., 2016). Delayed thoracotomy in chest injury results
in late empyema, fibrothorax, and other morbidities.
Abdominal sonography and chest X-rays in thoracic
injury should be accomplished routinely, including in
these patients (Mahoozi, H. R. et al., 2016; & Mock, C.
(Ed.). 2004).
Proper placement of chest tube on hemothorax case
will remove excess fluid from the pleural cavity. The
tube must be in the midaxillary line or posteriorly of the
anterior lateral line in a supine position, generally
placed in the sixth or seventh intercostal space. To
prevent blood clot obstruction, larger-diameter tubes
have been used for suspected hemothorax cases (Chen,
C. Y. et al., 2010; Mahoozi, H. R. et al., 2016; &
Broderick, S., & Hemothorax, R. 2013). Newly
prospective analysis of chest tube size compared size
28F to 32F tubes with 36F to 40F tubes in 293 patients
at a level I trauma center. The results discovered no
difference in the outcomes for previously placed chest
tubes. Chest tubes removal was considered when the
drainage production is less than 150 ml/24 hours
(Muchuweti, D., & Muguti, E. 2020; & Mahoozi, H. R.
et al., 2016).
Figure 6: Algorithm for the diagnostic and therapeutic approach of hemothorax. (Mahoozi, H. R. et al., 2016)
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The right thoracoabdominal incision has been
reported by Kim and Seo to gain access to the bleeding
source and treat injuries caused by a steel bar
penetrating the abdomen (Kim, K. T., & Seo, P. W.
2016). We gained access by performing simultaneous
thoracotomy followed by laparotomy. By widening the
operating area, the attempt to control bleeding became
easier. The definitive therapy for organ injury
management based on the severity of the injuries. From
this case, the hemothorax is caused by a direct
laceration to the chest blood vessels. Trauma to the lung
parenchymal from the thoracic wall penetration is
common and mostly self-limiting, although the injury
can result in occult hemopneumothorax. Chest imaging
and blood gas analysis were done during the patient
ICU admission to detect early complications and further
damage of the pulmonary parenchymal tissue. In this
patient, after the 12th day of postoperative control, there
was no sign of hemopneumothorax (Muchuweti, D., &
Muguti, E. 2020; & Kim, K. T., & Seo, P. W. 2016).
One of the causes of death in severe abdominal
injury is liver damage. It is responsible for 10% to 15%
mortality. The American Association for the Surgery of
Trauma (AAST) divided the severity of liver injuries
into six grading scales. Most patients admitted for liver
injuries have grade I, II, or III, and nonoperative
management are successfully treated. In contrast,
almost two-thirds of grade IV or V injuries require
laparotomy. In this case, the laceration of the liver is
more than 30% of the hepatic lobe. According to the
AAST liver trauma classification, this indicates a grade
IV liver injury that requires laparotomy (Todd, S. R.
2004). Intensive resuscitation during operation with
early institution of a massive transfusion protocol is
needed to preserve organ perfusion and reverse all
trauma-induced physiological derangements.
The WSES position paper classified traumatic
hepatic lesions into minor (grade I, II), moderate (grade
III), and major/severe (grade IV, V, VI). A laparotomy
surgery was performed based on the patient's clinical
condition. Patients with high-grade lesions (i.e., grade
IV-V laceration with parenchymal disruption involving
more than 75% of the hepatic lobe or more than 3
Couinaud segments within a single lobe) may treat
nonoperatively if the hemodynamic is stable. On the
other hand, “minor” lesions may need immediate
surgery when the patient arrives with hemodynamic
instability. Unstable conditions are described by the
systolic, mean arterial pressure < 65 mmHg dan blood
pressure is < 90 mmHg with clinical evidence of shock
with skin vasoconstriction (cool, clammy, decreased
capillary refill). Decrease level of consciousness and/or
shortness of breath, or > 90 mmHg but requiring
infusions/transfusions and/or vasopressor drugs and/or
admission base excess (BE) > -5 mmol/l or transfusion
requirement of at least > 4 units of packed red blood
cells within the first eight hours (Coccolini, F. et al.,
2016).
Based on the vital sign from this case, this patient
was in stable condition, but the ongoing bleeding could
be a life-threatening condition; thus, immediate
laparotomy should be performed. Based on WSES
classification, the patient had severe hepatic injuries
WSES grade III includes AAST-OIS grade IV–V
hemodynamically stable (Coccolini, F. et al., 2016).
The Pringle maneuver is a surgical technique for
abdominal operations that the hepatoduodenal ligament
is clamped with a surgical tool or by hand for a short
time. This maneuver is used during liver surgery to
reduce blood loss for a short duration. In this case,
using the Pringle maneuver followed by suturing the
wound and giving blood transfusions helped stabilize
the situation (Broderick, S., & Hemothorax, R. 2013; &
Coccolini, F. et al., 2016).
CONCLUSION
Management of thorax-abdominal trauma needs
contribution from a multidisciplinary discipline of the
medical team. A stab of the thoracoabdominal region is
associated with damage of organs, high morbidity, and
mortality. Life-threatening conditions require
immediate and appropriate thoracostomy and
laparostomy procedures to save the patient and prevent
long-term complications can be prevented early. The
best treatment approaches are made base on the clinical
condition, grade of injury, and the associated injuries.
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