Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
LETTER TO EDITOR  
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 176-177
Polytrauma patient with through and through penetrating rod in abdomen: Timing and team is of utmost importance in emergency management


1 Department of Emergency Medicine and Casualty Services, North eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, Meghalaya, India
2 Department of Anaesthesiology and Critical Care, North eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, Meghalaya, India

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Date of Web Publication13-Jul-2015
 

How to cite this article:
Md. Yunus, Karim HM, Hajong R, Singh VS. Polytrauma patient with through and through penetrating rod in abdomen: Timing and team is of utmost importance in emergency management. J Emerg Trauma Shock 2015;8:176-7

How to cite this URL:
Md. Yunus, Karim HM, Hajong R, Singh VS. Polytrauma patient with through and through penetrating rod in abdomen: Timing and team is of utmost importance in emergency management. J Emerg Trauma Shock [serial online] 2015 [cited 2019 Jun 17];8:176-7. Available from: http://www.onlinejets.org/text.asp?2015/8/3/176/160754


Dear Editor,

Through and through penetrating thoraco-abdominal injuries with foreign body in situ are rare but potentially life threatening. These patients may not manifest its seriousness at the trauma scene. Physicians must have a high degree of suspicion for shock in patients with penetrating thoraco-abdominal trauma who appear stable [1] and should refer as early as possible to a tertiary hospital or a trauma center.

A 30 years old male met an accident at 1:30 a.m. and was taken to a primary hospital where primary care was given. Emergency medical service ambulance brought him to our emergency department (ED) at 6:50 a.m. Primary survey revealed Glasgow Coma Scale (GCS) of 15/15, hypothermic with BP 95/58 mmHg, HR 132, and RR 40/minute, shallow but regular. Cervical spine normal with no history of loss of consciousness or vomiting found. Blood cross-match was sent, and speciality and super speciality referral was given.

Approximately, 3.5 feet long, 2 inch × 2 inch, L-shaped, rugged, and pointed iron rod was seen penetrating through and through just below the xiphisternum [Figure 1] and [Figure 2], which moves with respiration and heart beats. He also had fractured right humerus and left 10 th rib.
Figure 1: Rod penetrating through and through just below the xiphisternum

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Figure 2: Posterior exit wound just lateral to the vertebral transverse process

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Extended focused assessment by sonography for trauma (EFAST) revealed rod penetrating through the liver with hemoperitonium and left hemothorax. Patient was directly shifted to emergency operation theater with concurrent resuscitation with warm Ringer lactate and taken for emergency exploration under general anesthesia with invasive hemodynamics monitoring and special attention to positioning of the patient.

Intraoperatively, it was found that the rod had penetrated the left lobe of liver [Figure 3], passing dangerously near to aorta above the left renal vessels through the lesser omentum and by the side of spine touching upper border of pancreas. Immediately after removal of the rod, patient went to hemorrhagic shock due to sudden gush of bleeding, which was managed by rapid warm fluid and blood products. Liver was sutured and repair of damaged organ done. Rib fracture left untouched, and chest tube was inserted. Humerus fracture managed by closed reduction and immobilized with cast.
Figure 3: Rod penetrating the left lobe of liver

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Postoperatively he developed mild acute respiratory distress syndrome (ARDS) and shifted to the ward from ICU on 5 th postoperative day (POD) after weaning off from ventilator and was discharged to home on 12 th POD.

Abdomen is the third most commonly involved region of the body in trauma. [2] Liver and bowel are the frequently affected organs in abdominal trauma. [3] Penetrating abdominal and liver injury can be managed conservatively with serial clinical and radiological evaluation if the patient is hemodynamically stable. [4],[5] Current knowledge, literature, and guidelines [3],[4],[5],[6] recommend exploratory laparotomy for the patients who are unstable, having hollow viscus perforation, signs of peritonitis or where patient cannot be evaluated thoroughly owing to poor consciousness with head and cervical injury and intoxication. This holds true mostly for the penetrating injuries where the foreign body in no more in torso. On the other hand, penetrating abdominal injuries with foreign body in situ has to undergo operative management irrespective of above-mentioned clinical situations as the foreign body has to be removed from the body.

 
   References Top

1.
Menakar J, Scalea MT. Penetrating thoraco-abdominal injury. Trauma Rep 2010;11:1-11.  Back to cited text no. 1
    
2.
Hemmila MR, Wahl WL. Management of the injured patient. In: Doherty GM, editor. Current Surgical Diagnosis and Treatment. McGraw-Hill Medical; 2008. p. 227-8.  Back to cited text no. 2
    
3.
American College of Surgeons Committee on Trauma. In: Abdominal and Pelvic Trauma of Advanced Trauma Life Support for Doctors. 8 th ed. Ch. 5. Chicago: American College of Surgeons; 2008. p. 111-20.  Back to cited text no. 3
    
4.
Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010;68:721-33.   Back to cited text no. 4
    
5.
Schnüriger B, Talving P, Barbarino R, Barmparas G, Inaba K, Demetriades D. Current practice and the role of the CT in the management of penetrating liver injuries at a Level I trauma center. J Emerg Trauma Shock 2011;4:53-7.   Back to cited text no. 5
    
6.
Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-17.  Back to cited text no. 6
    

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Correspondence Address:
Md. Yunus
Department of Emergency Medicine and Casualty Services, North eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.160754

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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