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Penetrating trauma

Last updated: April 27, 2022

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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.

Gunshot injuries

  • 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]
    • Medium-velocity or high-velocity injuries [3]
    • Damage also caused to structures adjacent to the path of the bullet
    • Dense organs (e.g., liver, spleen) undergo more damage because they absorb more energy, resulting in greater injury.

Other penetrating injuries

  • Epidemiology
    • One of the most common forms of penetrating trauma globally
    • Mortality due to stab wounds 9.4 per 100,000 cases [4]
  • 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.

Etiology

Clinical features

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
  • Preliminary assessment and care
  • Surgical management
  • 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!

Etiology

Possible injuries

Clinical features

Approach to penetrating chest trauma

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.

Penetrating neck trauma [9][10]

  • 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
  • Approach to penetrating neck trauma

Penetrating trauma to the extremities [11]

  • 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.)
  • Clinical features: presentation depends on possible underlying injuries
  • 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
      • 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
  • 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]
  • 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
  • Diagnostics
  • Treatment: most patients require surgery
  • Complications: diaphragm paralysis

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

  1. Vassiliu P, Baker J, Henderson S, Alo K, Velmahos G, Demetriades D. Aerodigestive injuries of the neck. Am Surg. 2001; 67 (1): p.75-79.
  2. Penetrating Neck Injury. http://www.trauma.org/archive/vascular/neckmanage.html. Updated: June 1, 2002. Accessed: March 6, 2017.
  3. Ball CG. Penetrating nontorso trauma: the extremities. Can J Surg. 2015; 58 (4): p.286-288. doi: 10.1503/cjs.005815 . | Open in Read by QxMD
  4. Pestana C. Dr. Pestana's Surgery Notes: Top 180 Vignettes for the Surgical Wards. Kaplan ; 2015
  5. Haemothorax. https://radiopaedia.org/articles/haemothorax. Updated: February 16, 2016. Accessed: February 16, 2017.
  6. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  7. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis.. Am J Surg. 2015; 209 (5): p.864-8; discussion 868-9. doi: 10.1016/j.amjsurg.2014.12.023 . | Open in Read by QxMD
  8. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons. Committee on Trauma. Practice management guidelines for emergency department thoracotomy. J Am Coll Surg. 2001; 193 (3): p.303-309. doi: 10.1016/s1072-7515(01)00999-1 . | Open in Read by QxMD
  9. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy.. The journal of trauma and acute care surgery. 2012; 73 (6): p.1359-63. doi: 10.1097/TA.0b013e318270d2df . | Open in Read by QxMD
  10. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma.. The journal of trauma and acute care surgery. 2015; 79 (1): p.159-73. doi: 10.1097/TA.0000000000000648 . | Open in Read by QxMD
  11. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015; 79 : p.5-14. doi: 10.1016/j.ypmed.2015.06.002 . | Open in Read by QxMD
  12. Wintemute GJ. The Epidemiology of Firearm Violence in the Twenty-First Century United States. Annu Rev Public Health. 2015; 36 (1): p.5-19. doi: 10.1146/annurev-publhealth-031914-122535 . | Open in Read by QxMD
  13. Kuhajda I, Zarogoulidis K, Kougioumtzi I, et al. Penetrating trauma. J Thorac Dis. 2014; 6 (Suppl 4): p.S461-465. doi: 10.3978/j.issn.2072-1439.2014.08.51 . | Open in Read by QxMD
  14. Soreide E, Grande CM. Prehospital Trauma Care. CRC Press ; 2001

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