Penetrating trauma

Penetrating trauma is an injury caused by a foreign object piercing the skin, resulting in damage to underlying structures and an open wound. The most common types of penetrating injuries are gunshot wounds and stab wounds. Clinical features and diagnostic studies vary based on the type of penetrating trauma and the injured region of the body. The assessment of patients with penetrating trauma follows the systematic evaluation outlined in Advanced Trauma Life Support (ATLS): primary survey, transfer to a trauma center (if indicated), secondary survey, and tertiary survey. Management involves treating immediately life-threatening injuries and surgical repair of traumatic injuries.

See also “Management of trauma patients” and “Blunt trauma.”

Management of penetrating trauma is based on the type and location of the injury. Recommendations in this article are consistent with the 2018 ATLS algorithm. ^[1]

Stab wounds ^[1][2]

• Epidemiology: ∼ 1500 people die from stab wounds annually in the US ^[3]
• Mechanism of injury
  • Caused by the thrusting action of a pointed object (e.g., knife, broken bottle)
  • The depth of the injury is usually greater than the width.
  • Tissue is lacerated and torn along the path of the object.

Only remove impaled foreign bodies (e.g., knives) in settings where definitive hemostatic control is possible (e.g., operating room) as they might be tamponading injured blood vessels. ^[4]

Gunshot wounds (GSWs) ^[1][2]

• Epidemiology
  • Mortality rate for gunshot injuries in the US is 10.2 per 100,000 adults. ^[5]
  • Most deaths are due to firearm-related suicide rather than homicide (2:1). ^[6]
• Mechanism of injury
  • Tissue is lacerated and crushed along the path of the bullet.
  • Tissue is displaced forward and radially, resulting in cavitation and pressure injury of nearby structures.
  • The level of injury is related to the kinetic energy of the bullet; energy varies based on factors such as bullet weight and velocity.
  • Dense organs (e.g., liver, bone) absorb more kinetic energy than less dense organs, resulting in greater injury.

Sites of penetrating trauma ^[1]

Approach to penetrating chest trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Identify and treat respiratory failure and shock, tension pneumothorax, open pneumothorax, massive hemothorax, and cardiac tamponade (see “Treatment” for details).
  • If at a non-trauma center, initiate transfer to trauma center; penetrating injury to the torso is an indication for trauma team activation.
  • Perform resuscitative thoracotomy if indicated.
  • See “Traumatic circulatory arrest” for the management of cardiac arrest due to trauma.
• Secondary survey
  • Examine axillae, back, and flank for wounds that could enter the thoracic cavity.
  • Evaluate for penetrating thoracoabdominal and flank injuries.
  • Obtain urgent diagnostics for trauma patients, including CT chest, once stable (see “Diagnostics”).
  • Assess for indications for urgent thoracotomy.

Clinical features

• Hemorrhagic shock and/or obstructive shock (e.g., hypotension, tachycardia)
• Respiratory distress (e.g., tachypnea, hypoxia)
• Absent or decreased breath sounds
• Penetrating chest wound, e.g., sucking chest wound
• Impaled foreign body (e.g., knife)
• Beck triad
• Subcutaneous emphysema
• Tracheal deviation

Consider cardiac injury in patients with stab wounds to the cardiac box, i.e., a surface anatomy square bordered superiorly by the sternal notch, inferiorly by the xiphoid process, and laterally by the nipples. ^[7]

Diagnostics

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• Bedside assessment: CXR , eFAST
• CT imaging in trauma
  • CT chest with IV contrast
  • CTA chest if vascular injury is suspected.
• Additional testing: bronchoscopy, esophagoscopy, echocardiography

Do not delay treatment of clinically diagnosed tension pneumothorax to obtain radiologic confirmation. ^[1]

Treatment

Bedside interventions

Perform the following during the primary survey:

• Respiratory failure: RSI and mechanical ventilation
• Tension pneumothorax: Perform emergency chest decompression.
• Open pneumothorax: Place 3-sided occlusive dressing.
• Massive hemothorax: Place chest tube.
• Cardiac tamponade: Perform pericardiocentesis followed by pericardial window, or resuscitative thoracotomy.
• Loss of vital signs due to penetrating chest trauma: Perform resuscitative thoracotomy.

Urgent thoracotomy

• Definition: a surgical procedure performed in the operating room to obtain access to the thoracic cavity to treat acute injuries to thoracic organs (e.g., heart, lungs, esophagus)
• Indications
  • Hemorrhagic shock (e.g., hypotension, tachycardia)
  • Massive hemothorax; any of the following:
    • Chest tube output ≥ 1500 mL immediately upon placement
    • Chest tube output ≥ 200 mL/hour for 2–4 hours
    • Need for multiple blood transfusions
  • Impaled penetrating object
  • Cardiac tamponade
  • Open pneumothorax
  • Tracheobronchial tree injury (e.g., persistent air leak)
  • Esophageal injury

• Definition: : the accumulation of blood within the pleural space due to trauma
• Etiology: penetrating trauma, blunt trauma
• Clinical features
  • Hemorrhagic shock (e.g., hypotension, tachycardia)
  • Respiratory distress
  • Chest pain
  • Diminished or absent breath sounds
  • Decreased tactile fremitus
  • Dullness on percussion
  • Flat neck veins
  • Associated conditions
    • Flail chest: paradoxical movement, chest wall deformity
    • Pneumothorax: subcutaneous emphysema
• Diagnostics ^[8]
  • Upright CXR
    • Small hemothorax: unilateral blunting of the costophrenic angle ;
    • Large hemothorax findings include: ^[8]
      • Complete lung opacification
      • Mediastinal shift
      • Tracheal deviation away from the effusion
  • eFAST: hypoechoic or anechoic collection in the costodiaphragmatic recess ^[8]
  • CT chest with IV contrast: can detect hemothoraces not detected on CXR and additional injuries
• Treatment ^[1]
  • Consult thoracic surgery.
  • Chest tube insertion into the 5^th intercostal space at the midaxillary line is indicated in most patients.
  • Indications for urgent thoracotomy ^[1]
    • Chest tube output ≥ 1500 mL immediately upon placement
    • Chest tube output ≥ 200 mL/hour for 2–4 hours
    • Need for multiple blood transfusions
• Complications: pleural empyema, fibrothorax, trapped lung

Approach to penetrating abdominal trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Perform FAST exam and portable CXR.
  • Treat hemorrhagic shock with emergency transfusion and immediate hemodynamic support.
  • If at a non-trauma center, initiate transfer to a trauma center; penetrating torso injury is an indication for trauma team activation.
  • Identify obvious indications for exploratory laparotomy, e.g., hypotension, evisceration, peritoneal signs, subdiaphragmatic air on CXR.
• Secondary survey
  • Examine flank, back, and groin for wounds that could end the abdominal cavity.
  • Locally explore wounds for evidence of violation of the abdominal fascia.
  • Evaluate for penetrating thoracoabdominal and flank injuries.
  • Obtain urgent diagnostics for trauma patients, including contrast CT abdomen and pelvis, once stable (see “Diagnostics”).
  • Identify other radiological indications for exploratory laparotomy.

In persistently unstable patients with indications for exploratory laparotomy during the primary survey, do not delay operative management (e.g., damage control surgery) for CT scanning. ^[1]

Clinical features ^[1]

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Penetrating abdominal wound
• Impaled foreign body (e.g., knife)
• Signs of peritonitis
• Evisceration Protusion of intraabdominal organs through a wound to the outside of the body.

Significant intraperitoneal injury occurs in ∼ 98% of abdominal gunshot wounds and ∼ 30% of abdominal stab wounds. ^[1]

Diagnostics ^[1]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• General imaging in trauma: CXR, pelvic x-ray
• Bedside intraabdominal hemorrhage assessment: FAST or eFAST, or diagnostic peritoneal lavage (DPL)
• CT imaging in trauma
  • Minimum evaluation: CT abdomen and pelvis with IV contrast
  • If penetrating thoracoabdominal injury is suspected, add CT chest and consider double-contrast CT or triple-contrast CT.
• Minimally invasive surgical assessment
  • Local wound exploration
  • Diagnostic laparoscopy

Retroperitoneal injuries may be missed on DPL and FAST. ^[1]

If indicated, do not delay exploratory laparotomy to obtain CT scans. ^[1]

Exploratory laparotomy ^[1]

• Definition: an urgent surgical procedure in which the abdominal cavity is opened via a midline incision and the four quadrants are evaluated for pathologies (e.g., bleeding, perforation)
• Indications
  • Clinical
    • Hypotension
    • Peritoneal signs
    • Evisceration
    • Penetrating injury (e.g., GSW) with a trajectory that enters or traverses the peritoneal cavity
    • Evidence of GI, GU, or rectal bleeding
  • Diagnostic
    • Pneumoperitoneum and/or retroperitoneal air
    • Diaphragmatic rupture
    • GI, bladder, renal, or severe solid organ injury on CT
    • Positive DPL

Conservative management ^[9]

Consider the following in consultation with the trauma team for select stable patients without indications for exploratory laparotomy:

• 24-hour observation
• Vital signs monitoring
• Serial abdominal examinations
• Serial hemoglobin and hematocrit measurements
• Repeat imaging if clinical status changes
• Diagnostic laparoscopy in select patients, e.g., to identify diaphragmatic injury
• Other supportive care for trauma (See “Secondary survey” for details.)

Anatomic regions ^[1]

• Anterior thoracoabdominal: penetrating wound between the 4^th intercostal space (nipple line) and costal margin extending to the anterior axillary line bilaterally
• Posterior thoracoabdominal: penetrating wound between the 8^th intercostal space, costal margin, and posterior axillary lines
• Flank: penetrating wound between the anterior and posterior axillary lines, between the 6^th intercostal space and iliac crest

Injuries ^[1]

• Thoracic injuries, e.g., heart, lung, thoracic aorta
• Diaphragmatic injuries
• Abdominal injuries, e.g., liver, spleen, stomach, bowel
• Retroperitoneal organ injuries, e.g., kidney, abdominal aorta, ascending colon, descending colon

Management ^[1]

• Follow the ATLS algorithm and obtain beside diagnostics (e.g., CXR, eFAST).
• Combine the approach to penetrating thoracic trauma and the approach to penetrating abdominal trauma.
• Obtain CT chest, abdomen, and pelvis with IV contrast in stable patients.
• If hollow viscus perforation is suspected, consider: ^[9]
  • Double-contrast CT (IV and PO), e.g., for suspected proximal bowel injury
  • Triple contrast CT (IV, PO, and rectal), e.g., for suspected distal bowel injury ^[10]
• Evaluate for diaphragmatic injuries and retroperitoneal injuries.
• Urgent thoracotomy and/or exploratory laparotomy may be indicated; prioritize definitive care in consultation with specialists.
• If at a non-trauma center, initiate transfer to a trauma center; penetrating torso injury is an indication for trauma team activation.

Maintain a high index of suspicion for diaphragmatic injury and retroperitoneal injury in patients with stab wounds or GSWs to the thoracoabdominal and/or flank regions.

• Definition: an acquired defect (tear, perforation, or rupture) in the diaphragm that can result in an acquired diaphragmatic hernia
• Etiology: penetrating trauma (65%); blunt trauma (35%) ^[11]
• Clinical features
  • Often asymptomatic
  • Signs of chest and/or abdominal trauma
  • Clinical features of acquired diaphragmatic hernia
  • Clinical features of bowel obstruction
• Diagnostics: difficult to identify on imaging if there is no associated diaphragmatic hernia (see also “Diagnostics of acquired diaphragmatic hernias.”) ^[2]
  • CXR: can be used to screen unstable patients; may show thoracic bowel herniation but has poor sensitivity.
  • CT chest and abdomen: preferred initial modality for stable patients; findings include diaphragmatic discontinuity, diaphragmatic hernia, and hourglass sign.
  • Diagnostic laparoscopy and/or thoracoscopy: may be required in select patients
• Treatment: : reduction of herniated contents with surgical repair ^[12]
• Complications: diaphragm paralysis, mechanical bowel obstruction, bowel ischemia

Exercise caution when inserting a chest tube in patients with suspected diaphragm injuries to prevent injuring herniated abdominal structures. ^[1]

Approach to penetrating neck trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Prepare for difficult airway management and secure the airway early (see “Treatment”).
  • Consider C-spine immobilization if a C-spine fracture is suspected, e.g., focal neurological deficit, low GCS or intoxication, GSW. ^[13]
  • Apply direct pressure to active hemorrhage.
  • Assess for hard signs of penetrating neck injury requiring emergency surgery.
  • If at a non-trauma center, initiate transfer to a trauma center; penetrating neck injury is an indication for trauma team activation.
• Secondary survey
  • Examine neck wound without probing for violation of the platysma.
  • Perform neurological examination.
  • Obtain urgent diagnostics for trauma patients, including CTA neck, once stable (see “Diagnostics”).
  • Consult specialists depending on the injured anatomical structures (see “Disposition”).

Do not probe penetrating neck wounds as this can cause life-threatening bleeding.

Clinical features ^[2][14]

• Penetrating neck wound
• Impaled foreign body (e.g., knife)

Hard signs of penetrating neck injury ^[2]

The presence of any of the following increases the likelihood of life-threatening injury requiring surgical intervention often bypassing CT imaging:

• Airway or esophageal injury
  • Airway compromise
  • Wound bubbling
  • Extensive subcutaneous emphysema
  • Hoarseness and/or stridor
• Vascular injury
  • Hemorrhagic shock (e.g., hypotension, tachycardia)
  • Pulsatile bleeding
  • Expanding hematoma
  • Carotid bruit
  • Unilateral pulse deficit
  • Signs of stroke

Soft signs of penetrating neck injury

The presence of any of the following increases the likelihood of serious injury and often requires a CTA neck for further evaluation:

• Airway or esophageal injury
  • Hemoptysis and/or hematemesis
  • Dysphonia
  • Dysphagia
  • Mild subcutaneous emphysema
• Vascular injury
  • Minor bleeding
  • Nonexpanding hematoma
  • Proximity wound

Any penetrating neck trauma that violates the platysma requires surgical consultation. ^[13]

Cervical collars can obscure injuries. Remove the cervical collar and maintain manual inline cervical stabilization while examining the patient.

Classification

The following zones of the neck were classically used to predict which underlying structures might be injured and to guide management, however, this is being supplanted by the 'no zone' approach, which focuses on identifying hard signs of penetrating neck injury plus CTA for stable patients to guide management. ^[13][14]

• Zone 1: from the sternal notch to the cricoid cartilage
• Zone 2: from the cricoid cartilage to the angle of the mandible
• Zone 3: from the angle of the mandible to the skull base

Diagnostics ^[2]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• Bedside assessment: CXR, eFAST to rule out pneumothorax or apical lung injury from supraclavicular neck injuries
• CT imaging in trauma: CTA neck
• Additional testing: varies based on the suspected injury
  • Vascular injury: duplex ultrasound, angiography
  • Esophageal injury: esophagoscopy, esophagogram
  • Laryngeal injury: direct laryngoscopy, flexible nasopharyngoscopy

Treatment ^[1][2][15]

• Urgent surgical repair is typically indicated for vascular, laryngotracheal, and esophageal injuries.
• Esophageal perforation typically requires broad-spectrum antibiotics and NPO status.
• C-spine fractures can be treated operatively or nonoperatively (see “Vertebral fractures” for details).

Airway management ^[13]

• If there are signs of airway compromise, call for help immediately (e.g., emergent anesthesia or ENT consult).
• Perform BMV cautiously.
• Prepare for difficult airway management by an experienced provider.
  • Intubation via direct laryngoscopy or videolaryngoscopy using a smaller-sized ET tube can be attempted initially if anatomy is preserved.
  • Awake fiberoptic intubation is preferred for distorted anatomy.
  • Prepare for emergency surgical airway as a backup.
• If a cervical collar is applied, remove it and perform manual in-line cervical stabilization during airway management.

Cricothyroidotomy may be impossible if anatomic landmarks are invisible or deformed, e.g., due to a laryngeal fracture. Emergency tracheostomy may be required for a failed intubation. ^[1]

Disposition ^[2]

• Consult surgical subspecialties based on clinical and diagnostic findings.
  • Vascular injuries: vascular surgery
  • Laryngotracheal injuries: otolaryngology
  • Spinal fractures: orthopedic surgery
  • Esophageal injuries: thoracic surgery
• Admit asymptomatic patients with no concerning findings on CTA for serial examinations for 24–36 hours.

Approach to penetrating extremity trauma ^[1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

• Primary survey
  • Apply direct pressure and/or a tourniquet if there is active extremity hemorrhage.
  • Immobilize fractured limbs early.
  • If at a non-trauma center, initiate transfer to a trauma center for hard signs of extremity vascular injury; proximal limb penetrating injury is an indication for trauma team activation.
• Secondary survey
  • Perform detailed neurovascular examination of the affected extremity.
  • Provide supportive care, e.g., analgesia, tetanus prophylaxis.
  • Obtain urgent diagnostics for trauma patients, including x-ray and/or CTA extremity, once stable (see “Diagnostics”).
  • Determine if there is a need for surgical consultation based on injury characteristics (e.g., vascular surgery, orthopedic surgery)

Clinical features

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Penetrating extremity wound
• Impaled foreign body (e.g., knife)
• Neurological deficit (e.g., loss of strength and/or sensation)
• Acute compartment syndrome

Hard signs of extremity vascular injury ^[16]

• Active hemorrhage
• Absent distal pulses
• Pulsatile hematoma
• New bruit
• Distal ischemia

Diagnostics

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

• Vascular injury
  • Arterial-brachial index (ABI)
  • CTA of the injured limb ^[17]
  • Duplex ultrasound
• Bony injury: x-ray of the injured limb

Treatment

• Vascular injury
  • Hemostatic control
  • Consult vascular surgery for patients with hard signs of extremity vascular injury or abnormal imaging.
• Fracture
  • Immobilize with a splint (see “Upper extremity splints” and “Lower extremity splints” for details).
  • Consult orthopedic surgery and provide antibiotic prophylaxis for open fractures.

Consider any penetrating wound with a concomitant fracture an open fracture until proven otherwise. ^[1]

Disposition ^[17]

• Patients with suspected vascular injury or open fracture typically require admission and specialist consult.
• Patients without clinical features of vascular injury and an ABI > 0.9 may be discharged with return precautions for signs of compartment syndrome.

High-pressure injection injuries are surgical emergencies. The extent of the injury is often underestimated; extensive soft tissue loss can occur without prompt treatment.

• Etiology: often results from working with or cleaning the nozzle of machines that spray fluids at high pressure (e.g., paint guns, grease guns, concrete injectors, diesel fuel jets) ^[18]
• Clinical features
  • Small entrance wound
  • Often affects the nondominant hand
  • Early presentation: no symptoms or mild symptoms
  • Late presentation
    • Swelling, pallor, resting pain
    • Severe tenderness to palpation
    • Severe pain with passive motion
• Imaging: Obtain x-rays of the extremity for all patients.
• Initial management ^[2][18]
  • Identify injected substances if possible and consult poison control as needed.
  • Manage acute pain.
  • Urgently consult hand surgery for all patients with injection injuries involving the hand.
  • Urgently consult a qualified surgeon for forearm injection injuries (e.g., orthopedic surgery, plastic surgery).
  • Initiate prophylactic broad-spectrum antibiotics.
  • Administer tetanus prophylaxis if indicated.
• Definitive treatment
  • Most symptomatic patients: surgical exploration and debridement
  • Patients without symptoms several hours after injection with:
    • Water or air: conservative management (observation)
    • Other solvents: based on specialist recommendations
• Complications
  • Acute compartment syndrome
  • Tissue loss
  • Infection
  • Amputation: The risk varies based on the type and volume of material injected and the injection pressure. ^[18]

High-pressure injection injuries with organic solvents are considered surgical emergencies even if entrance wounds are small and the patient is asymptomatic at initial presentation. ^[2]