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A CASE PRESENTATION AND DISCUSSION ON PENETRATING
CHEST INJURY
BY:Martin Joseph S. Cabahug M.D.
Ospital ng Maynila Medical CenterDepartment of Surgery
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General Data:
J.H. 37 y/o, male
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Chief Complaint:Stab Wound
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HPI:NOI: Stab Wound POI: Sta Ana Mla.DOI: 9-12-04 TOI: 1:30am
1 Hour PTA Stabbed at the back
OMMC
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Physical Examination
General Survey: Conscious, coherent
in mild respiratory distress
BP: 110/70 CR: 90 RR: 30HEENT: Pink palpebral conjunctivae,
anicteric sclerae, moist lipsNECK: supple. No CLAD, (-) NVE
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Physical Examination
CHEST AND LUNGS:
• SCE, no retractions,• (+) stab wound
midscapular line left level of T6
• decreased breath sounds left lung field
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HEART: adynamic precordium, NRRR, no murmur
ABDOMEN: Flat, normoactive bowel soundssoft, non tender
EXTREMITIES:full and equal pulses, no gross deformities, (-) edema
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Salient Features
Primary survey• 34 y/o male• (+) stab wound midscapular line left
level of T6• In respiratory distress• Decreased breath sounds left lung field
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Algorithm
stab wound
penetrating non penetrating
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Algorithm
stab wound
penetrating non penetratingdyspneadecrease in breath sounds
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Algorithm
penetrating
pulmonary cardiac stable bp
- audible heart sounds
dyspneadecrease in breath sounds
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Algorithm
penetrating pulmonary
Hemothorax Pneumothorax
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Clinical Diagnosis
40%Pneumothorax left secondary to stab wound midscapulararea level of T6
Secondary Diagnosis
60%Hemothorax left secondary to stab wound midscapulararea level of T6
Primary Diagnosis
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Do I need a Paraclinical diagnostic Procedure?
NO
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Goals of Treatment
• Re-expansion of the lung• Correct ventilatory insufficiency• Adequate drainage
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Treatment Options
available300-nil-Useful in small
hemothorax/ pneumthorax--time consuming-Minimal pain
Thoracentesis
available1000-Injury to adjacent structure
-Rapidevacuation of fluid/air-substantial pain
Tube Thoracostomy
AvailabilityCostRiskBenefit
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Treatment Options
available300-nil-Useful in small
hemothorax/ pneumthorax--time consuming-Minimal pain
Thoracentesis
available1000-Injury to adjacent structure
-Rapidevacuation of fluid/air-substantial pain
Tube Thoracostomy
AvailabilityCostRiskBenefit
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Preoperative Preparation
• Inform consent• Secure materials
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• Patient semi-sitting with the ipsilateral arm placed above the head
• to expose the lateral aspect of the chest• chest prepared with antiseptic solution• draped to create a sterile field• large bore chest tube (36 Fr) chosen to
facilitate adequate drainage
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• 5th ICS midaxillary line identified anesthesized with 1% lidocaine
• transverse incision made over the 5th rib• blunt dissection continued with Kelly clamp• clamp passed adjacent to the superior
surface of the rib to prevent injury to the intercostals neurovascular bundle
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• entry into the pleural space confirmed with gush of blood-filled fluid
• finger inserted into the pleural space• a Fr 36 chest tube inserted into the pleural
space on a Kelly clamp and directed posteriorly
• tube secured with a silk 0 suture
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• attached to a water sealed drainage system • insertion site dressed with sterile gauze and
covered with air-tight dressing• initial drainage recorded
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• FINDINGS:(+) 1200cc of blood evacuated with good fluctuation.
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Pretreatment Diagnosis
20%Hemothorax left secondary lung parenchymal injury
Secondary Diagnosis
80%Hemothorax left secondary bleeding intercostal vessel
Primary Diagnosis
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Goal of Treatment
-Control of bleeders-Re expansion of lungs
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Treatment Options
Notavailable
*****-Injury to adjacent structure
-Limited field-Less pain post op-Operator dependent
VATS
available**- Injury to adjacent structure
-clear visualization of bleeders
Open Thoracotomy
AvailabilityCostRiskBenefit
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Treatment Plan
- Open Thoracotomy
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• Informed consent was secured• Provide psychosocial support• Patient was then directed to OR for
thoracotomy
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operative technique
• Patient supine under GA• Asepsis/Antisepsis• Sterile drapes placed• Anterolateral thoracotomy incision done on the
4th ICS from the parasternal border to the MAL from skin down to the subcutaneous, muscular and pleural layers
• Rib retractors applied• Findings noted
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• OR FINDINGS- 1L blood evacuated with clots, thru and thru lung injury with bleeding intercostal vessels
• Lung injury repaired with vertical mattress sutures using chromic 2-0
• Lavage done• Anterior and posterior chest tube placed• Hemostasis• Correct instrument and sponge count• Fascia closed with Vicryl O• Skin closed with silk 3-0• DSD
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Final DiagnosisHemothorax, L secondary to
transected intercostal vessels secondary to stab wound midscapular area L, at the level of T6
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Post operative management
1st PO Day• NPO• Maintain O2 inhalation at 3-4 LPM via
nasal• 1 “U” of PRBC transfusion obtained• Adequate antibiotics• Adequate analgesia
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Post operative management
2nd PO day• NPO• IV meds continued• Blow Bottle exercise• Chest Physiotherapy• Change Thora bottle• Foley catheter removed
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Post operative management
5th PO day• Chest xray• Anterior CTT removed• GL• IV meds continued
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Post operative management
8th PO day• DAT• Chest xray• Posterior CTT removed• Shifted to Oral Meds
Co- Amoxiclav 625mg Q8
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Post operative management
9th PO day• DAT• Chest xray• discharged
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Discussion
HemothoraxDefined as the collection of blood in the
pleural space. Most commonly caused by blunt or penetrating trauma and is often seen in patients with multiple injuries
Overall most cases of hemothorax are satisfactorily treated by adequate drainage usually by chest tube thoracostomy and only 10-15% of patients require thoracic surgical intervention.
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DiscussionDIAGNOSIS OF ACUTE HEMOTHORAX
• History of the mechanism of injury• Physical examination• Diminished breath sounds• Dullness on percussion on the affected side• Chest radiography• Up to 300 ml of fluid may collect before
hemothorax can be detected
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DiscussionIn the setting of blunt trauma
Associated chest injuriesRib fracturesFlail chestPulmonary parenchyma contusion
Massive HemothoraxShockSevere ventilatory insufficiencyMediastinal shiftWith contralateral tracheal deviation
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Algorithm for Treatment of Hemothorax
HEMOTHORAX
Small <500ml >500 ml Traumapneumothorax
THORACENTESIS TUBE THORACOSTOMY
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Algorithm for Treatment of Hemothorax
HEMOTHORAXMassive collection>1500ml>200ml/hr for 4 hrs>2000ml/24hrs
OPEN THORACOTOMY
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TUBE THORACOSTOMY
Complete evacuationNo ongoing bleeding
RetainedCollection
MAINTAIN CTT AND OBSERVE
>1/3 lung volume<1/3 lung volume
SUCTIONING
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MCQ Questions1 In a patient with hemothorax, L s/p CTT
left on chest x-ray retained hemothorax1/3 of lung volume, what is the appropriate measure
a. Maintain CTT and observeb. Direct patient to OR for
suctioning under sedationc. Open thoracotomyd. Insert another CTT
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MCQ Questions1 In a patient with hemothorax, L s/p CTT
left on chest x-ray retained hemothorax1/3 of lung volume, what is the appropriate measure
a. Maintain CTT and observeb. Direct patient to OR for
suctioning under sedationc. Open thoracotomyd. Insert another CTT
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MCQ Questions
2 What amount of blood in the pleura would be considered as massive hemothorax
a. 500mlb. 700mlc. 800mld. 1500ml
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MCQ Questions
2 What amount of blood in the pleura would be considered as massive hemothorax
a. 500mlb. 700mlc. 800mld. 1500ml
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MCQ Questions
3 What amount of blood in the pleura would cause blunting of the costophrenic angle in an adult patient
a. 100mlb. 200mlc. 300mld. 500ml
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MCQ Questions
3 What amount of blood in the pleura would cause blunting of the costophrenic angle in an adult patient
a. 100mlb. 200mlc. 300mld. 500ml
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MCR Questions
4 Patient with stab wound at the anterior chest, has dyspnea, hypotension, with muffled heart sounds with minimal blood loss, what would be the appropriate measure
a. CTTb. pericardiocentesisc. Fluid resuscitationd. Subxiphoid window
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MCR Questions
4 Patient with stab wound at the anterior chest, has dyspnea, hypotension, with muffled heart sounds with minimal blood loss, what would be the appropriate measure
a. CTTb. pericardiocentesisc. Fluid resuscitationd. Subxiphoid window
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MCR Questions
5 Massive hemothorax can cause the following:
a. Ventilatory insufficiencyb. Mediastinal shiftc. Shockd. Contralateral tracheal deviation
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MCR Questions
5 Massive hemothorax can cause the following:
a. Ventilatory insufficiencyb. Mediastinal shiftc. Shockd. Contralateral tracheal deviation
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REFERENCES
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2. Naunhein, Keith; Baue, Arthur E. Penetrating Chest Injury, General Thoracic Surgery: 644-650
3. Schwartz, S. Principles of Surgery. 7th edition, Vol II: 1182
4. MD consult- Journal