Summary
Penetrating trauma is an injury caused by a foreign object piercing the skin, which damages the underlying tissues and results in an open wound. The most common causes of such trauma are gunshots and stab wounds. Clinical features differ depending on the injured parts of the body and the shape and size of the penetrating object. Diagnosis is established based on history and imaging studies (X-rays, CT/MRI). Management usually involves supportive measures (hemostasis, blood transfusion, respiratory support), and surgical repair of damaged structures and/or removal of foreign bodies.
General information
Gunshot injuries
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Epidemiology
- Mortality due to gunshot injuries in the USA is 10.2 per 100,000 cases [1]
- More suicidal firearm-related deaths than homicidal deaths (2:1) [2]
- Mechanisms of injury [3]
Other penetrating injuries
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Epidemiology
- One of the most common forms of penetrating trauma globally
- Mortality due to stab wounds 9.4 per 100,000 cases [4]
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Mechanism of injury
- Usually caused by a sharp, impaling object (e.g., knife, ice pick, broken bottle)
- Low-velocity injuries
- Hemorrhage and infection are the most significant mechanisms responsible for morbidity and mortality.
Penetrating abdominal trauma
Etiology
- Most common: gunshot wounds (64% of all penetrating abdominal trauma)
- Stab wounds
Clinical features
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Visible entry wounds
- Sites of injury
- Gunshot wounds: most commonly small bowel, colon, and liver
- Stab wounds: most commonly liver, small bowel, and diaphragm
- Sites of injury
- Signs of abdominal bleeding: hypotension; , tachycardia; , cyanosis, anxiety; , flank discoloration, shock
- Pain; , abdominal rigidity; , and distention
- Abdominal compartment syndrome
Any wound located anteriorly between the nipple line (T4) and the groin creases, and posteriorly between T4 and the curves of the iliac crests is considered a potential penetrating abdominal injury!
Approach to penetrating abdominal trauma
- History: details such as number of shots heard, amount of blood loss at the scene of injury, and position of patient when shot or stabbed
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Preliminary assessment and care
- Prehospital and hospital trauma care
- Resuscitative and stabilization procedures; (e.g., rapid transfusions; , CPR) indicated if the patient is hemodynamically unstable
- Tetanus prophylaxis
- Broad spectrum antibiotic prophylaxis
- Analgesics, anxiolytics
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Surgical management
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Emergency exploratory laparotomy ; indicated in
- Evisceration
- Signs of peritonitis
- Hemodynamic instability
- Bleeding detected in nasal tube or rectal examination
- Penetrating object still in situ (risk of precipitous hemorrhage on removal)
- Free air under the diaphragm
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Assess for peritoneal or retroperitoneal penetration and intra-abdominal bleeding
- FAST exam
- CT/MRI imaging
- Local wound exploration
- Diagnostic peritoneal lavage (DPL)
- Diagnostic laparoscopy
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Emergency exploratory laparotomy ; indicated in
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Conservative management
- Indications: surgical treatment not required
- Measures
- Close monitoring of vital signs
- Serial physical examinations
- Blood analysis to monitor hemodynamic state
- Repeat imaging as needed
Penetrating trauma below the nipple line (4th intercostal space) essentially involves the abdomen and may require an emergency exploratory laparotomy.
In cases of gunshot wounds, an entry wound in almost any part of the body can result in a penetrating abdominal injury, depending on the path the bullet may have taken through the body. This makes a comprehensive clinical and imaging-based assessment vital.
Patients without evidence of peritonitis, evisceration, and hemodynamic instability may undergo CT prior to surgical intervention.
Penetrating objects often tamponade the wound and should be removed only in a setting where definitive care is possible!
Penetrating chest trauma
Etiology
- Gunshot wounds
- Stabbing
Possible injuries
- Hemothorax
- Pneumothorax
- Rib fractures
- Organ injury: mediastinum, pericardium, tracheobronchial tree, diaphragmatic rupture
- Vascular injury: subclavian artery, internal thoracic artery, aorta, venae cavae
Clinical features
- Injury to lung parenchyma, pulmonary contusion, tracheobronchial injury → hypotension, hypoxia, persistent tachycardia
- Pneumothorax → diminished breath sounds
- Pneumothorax, tracheobronchial injury → cutaneous crepitus
- Lung or pericardium injury → persistent dyspnea or severe, pleuritic chest pain
- Tracheal or esophageal injury → change in voice or foreign body sensation
- Pericardial effusion → jugular venous distention
Approach to penetrating chest trauma
- Preliminary assessment and care: See “Preliminary assessment and care” in approach to penetrating abdominal trauma above.
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Emergency procedures
- Needle decompression followed by a chest tube for tension pneumothorax
- Placement of an occlusive dressing, taped on three sides, for a sucking chest wound
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Resuscitative thoracotomy; (RT): also called emergency department thoracotomy, EDT, bedside thoracotomy, or emergency thoracotomy
- Should only be performed if a trained and experienced surgeon is present
- Survivors are expedited to the operating room for definitive surgical management
- Maneuvers include
- Evacuation of cardiac tamponade
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Hemostasis of exsanguinating cardiac or vascular injuries
Aortic cross-clamping to control abdominal hemorrhage - Open cardiac massage.
- Indications [5][6][7][8]
- Cardiac arrest that occurred at, or after, presentation, or is imminent
- Pulseless patients with signs of life after penetrating chest trauma
- May be performed prehospital (e.g., in an ambulance) or in the emergency department.
- An emergency procedure used as a last resort to resuscitate patients at imminent risk of death from major trauma
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Urgent thoracotomy: performed in the operating room to treat acute conditions/injuries of thoracic organs that require immediate surgical attention (within 48 hours of injury).
- Indications include: [5]
- Hemodynamically unstable patient
- Penetrating object still in-situ and/or mediastinal penetration
- Cardiac tamponade
- Massive or continuous hemorrhage from the chest tube
- Massive air leak
- Evidence of severe organ injury
- Indications include: [5]
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Emergency pericardiocentesis with catheter
- Indication: provides temporary pericardial decompression secondary to a life-threatening cardiac tamponade if a thoracotomy cannot be conducted quickly
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Assessment of injury cause and severity
- Ultrasound (Extended Focused Assessment with Sonography in Trauma, EFAST)
- Chest x-ray and/or CT if patient is stable
- Others: echocardiography, endoscopy, bronchoscopy, angiography
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Further management
- Close monitoring of vital signs
- Continual reassessment
- Appropriate surgical repair after hemodynamic stabilization
- Repeat imaging as needed
Consider concomitant intra-abdominal injuries in cases of injury either below the nipples or the inferior scapular angle.
Penetrating objects should only be removed in the operating room.
Other types of penetrating injury
Penetrating neck trauma [9][10]
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Etiology
- Stab injuries: low velocity injuries by any sharp impaling objects (knives, pens, broken glass, etc.)
- Ballistic injuries: gunshots, missiles (shrapnel, darts, projectiles, etc.)
- Clinical features: features of injuries to the neck can be divided into
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Approach to penetrating neck trauma
- Preliminary assessment and care: See “Preliminary assessment and care” in “Approach to penetrating abdominal trauma“ above.
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In case of presence of hard signs:
- Immediate intubation and surgical exploration: in cases with hemodynamic instability, expanding hematoma, or clear signs of tracheal/esophageal injury
- Emergency tracheostomy: if integrity of larynx is in question
- Further management
- Determine injury extent: CT angiography (best initial test), esophagram, panendoscopy
- Gunshot wound: conservative or surgical management based on injury extent
- Stab wounds: Patients with no signs of severe vascular or organ injury can be safely observed.
Penetrating trauma to the extremities [11]
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Etiology
- Ballistic injuries (most commonly in a military setting; gunshots, shrapnel, projectiles)
- Stab injuries (due to sharp objects like knives, vehicular parts in road traffic accidents, rods, etc.)
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Clinical features: presentation depends on possible underlying injuries
- Vascular injuries: Hard signs of arterial injury include active hemorrhage, expanding or pulsatile hematoma, bruit or thrill over the wound, absent distal pulses, and extremity ischemia.
- Nerve injuries: loss of sensation or function of the affected limb
- Skeletomuscular injuries
- Pain
- Deformity, loss of function - in cases of muscle injury or fractures
- Acute compartment syndrome
- Crush syndrome (the complex of electrolyte disturbances, metabolic acidosis and rhabdomyolysis resulting from crush injury)
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Management [12]
- The approach is based on anatomic location and whether major vessel injury is suspected
- No major vessels in the vicinity of the tract of the penetrating object: conservative management
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Stable patients with a penetration tract in the vicinity of major vessels and local signs (pain/tenderness), but no systemic signs of hypovolemia, should undergo further diagnostic testing:
- Plain x-ray; : evaluate extent of bony injury
- Contrast CT angiography; : evaluate vascular injury
- Doppler ultrasonographic evaluation: evaluate vascular injury in cases with poor renal function, in which contrast CT is contraindicated
- Patients exhibiting 'hard signs' of arterial injury: urgent surgical exploration, hemorrhage control, and repair
- In case of combined injury to arteries, nerves and bones: start with stabilization of bone (fracture reduction etc.) → vascular repair → nerve repair
- The approach is based on anatomic location and whether major vessel injury is suspected
Diaphragmatic rupture
- Definition: a complication of blunt trauma or penetrating trauma in which abdominal contents herniate through the diaphragmatic defect into the thorax
- Etiology: penetrating injuries (65%), blunt trauma (35%) [13]
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Clinical features
- Often initially asymptomatic
- Chest/abdominal wall bruises
- In case of herniation of abdominal organs into the chest
- Decreased breath sounds, bowel sounds in the thorax, respiratory distress
- Signs of bowel obstruction
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Diagnostics
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Chest x-ray
- Disturbed contour of the hemidiaphragm
- Hourglass sign: displaced abdominal organs (esp. stomach and bowel segments)
- Possible mediastinal shift
- Nasogastric tube visible above the left hemidiaphragm
- Ultrasound FAST: rapidly detect large tears or herniation
- CT scan to confirm the diagnosis
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Chest x-ray
- Treatment: most patients require surgery
- Complications: diaphragm paralysis
Traumatic hemothorax
- Definition: : collection of blood within the pleural space due to trauma
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Etiology
- Most commonly due to penetrating or blunt trauma
- See also nontraumatic hemothorax for nontraumatic causes.
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Clinical features
- Dyspnea and diminished/absent breath sounds
- Decreased tactile fremitus, dullness on percussion
- Chest pain
- Flat neck veins, hemorrhagic shock and respiratory distress in severe hemorrhage
- Chest wall deformity
- Paradoxical chest wall movement
- Crepitus on palpation
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Diagnostics [14]
-
Chest x-ray ; : similar appearance to pleural effusion
- Opacity
- Blunting of the costophrenic angle
- Tracheal deviation (mediastinal shift)
-
Ultrasound: detection of smaller amounts of fluid/blood than on chest x-ray possible
- A hyperechogenic signal is first seen in the costodiaphragmatic recess.
- Commonly used in the FAST protocol for trauma assessment
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Chest x-ray ; : similar appearance to pleural effusion
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Treatment
- Chest tube insertion into the 5th intercostal space at the midaxillary line
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Thoracotomy indicated if
- Chest tube output > 1500 mL; immediately after placement or 200 mL/hour for 2–4 hours [5]
- Multiple transfusions required
- Complications: pleural empyema ; fibrothorax and trapped lung
A hemothorax, however small, must always be drained because blood in the pleural cavity will clot if not evacuated, resulting in a trapped lung or an empyema