Case Report Penetrating Thoracoabdominal Injuries from an ...

IAR Journal of Medical Case Reports ISSN Print : 2709-3220 | ISSN Online : 2709-3239 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iarjmcr

Available: https://iarconsortium.org/journal-info/iarjmcr 27

Penetrating Thoracoabdominal Injuries from an Iron Fence: Case Report and Literature Review

Abstract: Penetrating injuries through the abdomen and thorax have a higher

impact on morbidity and mortality than injuries inside one of them. Resuscitation

and Handling properly in early stages will bring good results to the patient.

Keywords: injuries, thoracotomy, laparotomy, penetrating, iron fence, thorax-

abdominal, liver.

INTRODUCTION Penetrating injuries through the abdomen and thorax have a higher

impact on morbidity and mortality than injuries inside one of them.

Foreign objects that enter the body cavities should not be detached prior

the patient’s arrival in the operating room (Muchuweti, D., & Muguti, E.

2020). Trauma is the third most prevalent cause of mortality after

cardiovascular disease and cancer and the leading cause of mortality in

patients under 40 years old (Petrowsky, H. et al., 2012). Injury of the

abdomen is an usual cause of death, accounting for 7-10% of trauma

patients. The condition will depend on injured organs and hemodynamic

stability (Johnson, J. J. et al., 2013). Presentation of penetrating

abdominal and chest trauma can provide clinical features of

pneumohemothorax, hemothorax, cardiac tamponade, pneumothorax,

airway obstruction, and pulmonary contusion (Shanmuganathan, K., &

Matsumoto, J. 2006).

Penetrating abdominal injuries can be extended to the intrathoracic

organ, which may present with massive hemoperitoneum due to the

mesentery injury, gaster, spleen, liver, or peritonitis from bowel

perforations. Abdominal stab wounds usually affect hollow viscus organs

(Biffl, W. L., & Moore, E. E. 2010). Foreign bodies that stab intra-

abdominal or chest have a tampon effect, and attempts to remove them

before surgery increase the severity and risk of death. (McDonald, A. A.

et al., 2018).

A total of 1359 patients from 2004 study with traumatic injury of the chest at a United States level I trauma center

figured that only 18% of patients needed tube thoracostomy and 2.6% required advanced thoracotomy (Shanmuganathan,

K., & Matsumoto, J. 2006). The severe injury cases happened from blunt trauma, and the overall death was 9.45%.

Immediate thoracotomy and laparotomy are essential for managing double cavity injuries and retrieving foreign materials

(DeBarros, M., & Martin, M. J. 2015).

ILLUSTRATION

Four hours before admission to the hospital, while a 24 years old Mr. H was repairing the roof of the house by

climbing over the fence, the patient suddenly lost his balance and then slipped from the roof. The patient fell with his

chest position of the lower right abdomen stuck at the end of the open gate in a standing position. The others were

released by lifting the patient's body from the bottom up. After being released from the entrance, one end of the fence

was broken and allegedly left inside the patient's body. After the incident, the patient complained of abdominal and chest

pain. The patient was immediately taken to Sukoharjo District Hospital by rescue workers, put on IV lines, stitched up

the wound, injected with analgetic, and did a chest X-ray. Parts of the iron fence were left in the stomach and chest.

Because of this condition, the patient must get an assessment and intervention of the thoracic and digestive in Dr.

Moewardi Surakarta Hospital.

Case Report

Article History

Received: 20.07.2021

Revision: 31.07.2021

Accepted: 10.08.2021

Published: 20.08.2021

Author Details Imam Hafidh Zaini*1, Pigur Agus Marwanto1,

Agus Raharjo2 and Arif Prasetyo Utomo3

Authors Affiliations 1General Surgery Resident Faculty of

Medicine, Sebelas Maret University, Indonesia 2Digestive Division, Surgery Department,

Faculty of Medicine, Sebelas Maret

University, Indonesia 3Thoracic and Cardiovascular Division,

Surgery Department, Faculty of Medicine,

Sebelas Maret University, Indonesia

Corresponding Author* Imam Hafidh Zaini

How to Cite the Article: Imam Hafidh Zaini, Pigur Agus Marwanto,

Agus Raharjo, & Arif Prasetyo Utomo.

(2021); Penetrating Thoracoabdominal

Injuries from an Iron Fence: Case Report and

Literature Review. IAR J Med Cse Rep. 2(4),

27-33.

Copyright @ 2021: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited.

DOI: 10.47310/iarjmcr.2021.v02i04.007

Imam Hafidh Zaini, et al., IAR J Med Cse Rep; Vol-2, Iss- 4 (July-Aug, 2021): 27-33

28

The patient was a healthy young male with stable

hemodynamic. No sign of anemia and cyanosis in

mucous membranes were found. His blood pressure was

130/80 mmHg, pulse was 108 beats per minute, and

respiratory rate was 28 breaths per minute. Oxygen

saturation level on free air was 94%. Chest examination

showed breathing from the left chest was higher than

the right one. The laceration was sutured with 3.0

nonabsorbable multifilament thread at midaxillary line

sixth intercostal and abdominal above the right inguinal

line. Physical examination revealed lacerations in the

chest and lower right abdomen. On percussion, lung

sounds dim at the level of 5-8 ribs.

(a) (b)

Figure 1. Picture of patient in the emergency room before operating surgery (a) front view and (b) right side view

The patient was given oxygen 10 liters per minute

with a non-rebreathing mask, ringer lactate infusion,

human tetanus immunoglobulin injection 250 UI, and

ampicillin injection 1 g every 8 hours. Breathing

clearance with chest tube placement on the right chest

was performed, produced 300 ml of blood. Before

entering the operation room, the blood production rate

was 200 ml per hour. A nasogastric tube (NGT) was

inserted to drained the bleeding and removed

exaggerated gas from the intra-abdominal cavity. A

transurethral catheter was placed for urine output

measurement. Complete blood count, blood glucose,

FAST, X-ray of the thorax and abdomen were done.

Laboratory results showed low hemoglobin level (9.5

g/dL), elevated white blood cells (18.2 × 103Cells/L),

segmental neutrophil 88.7%, and elevated liver enzyme

(SGOT 391 U/L). The blood gas analysis found pH:

7.565, BE: 3.6 mmol/L, PO2:76.6 mmHg, and lactate

serum increased to 2.5 mmol/L. Minimal hemorrhage in

Morrison pouch was found during FAST examination.

There was also probe tenderness in the epigastric and

the right hypochondriacal to the right lumbar region. X-

ray examination showed that a foreign body penetrating

the lungs and damage to organs in the abdomen couldn't

be evaluated. We managed the case with open surgery.

(A) (B)

Figure 2. Chest x-ray before and after chest tube insertion

Thoracotomy and laparotomy were done

simultaneously with caution on the emergency area that

must be managed first. The foreign object, the green

iron fence, damaged the right pleura and penetrated the

diaphragm. The patient laid in the left lateral decubitus

position and was sedated with general anesthesia. The


29

operation began with an aseptic procedure, and then a

15 cm long incision was made on the 6th

ICS at the

posterolateral region, deepened to the intercostal

muscle. The incision was made above the right sixth

rib, anterior to the midaxillary line. Serratus anterior

muscle was preserved by cutting the fascia on the

posterior side. Elevation of the scapula was performed.

The sixth ICS was identified by palpating the ribs under

the scapula (the second ribs at the most prominent part).

One lung procedure was completed and the right lung

was deflated. Dissection above the seventh rib was

performed, opened the parietal pleura. A blood clot was

discovered in the pleural cavity. The foreign object

went through the medial side of the diaphragm with the

tip attached to the pericardium. It was pushed towards

the diaphragm. The diaphragm perforation (diameter 2

cm) was repaired with a simple interrupted 4.0

nonabsorbable monofilament thread. Chest tube

thoracotomy no.28 was inserted into the pleural cavity,

then connected to a single bottle WSD. The production

of WSD was 300 ml of blood from the right pleural

cavity, which was suction out. The chest tube fixated

with lived knots.

Figure 3. Exploratory Thoracotomy procedure followed by insertion of a chest tube

Laparotomy was done in a supine position under

general anesthesia. Midline incision 2 cm below the

xiphoid process of the sternum was made, followed by

dissecting along 20 cm the abdominal wall layer by

layer until the peritoneum was found. The ripped from

the peritoneum was 3 cm as high as the 12th

ribs. The

stomach, spleen, jejunum, ileum, and colon were

identified in good condition. Blood clots and bleeding

were found under the liver, and then the evacuation

procedure was performed. Green iron fierce was

penetrated the liver in VIII zones. Extraction of the

foreign material was carried out, obtained metal with a

conical shape, 15 cm of length and 5 cm of diameter.

Hepatic rupture grade IV was found, and the bleeding

was controlled using a pringle maneuver for the time

being. The liver was pressed with gauze. After 15

minutes of evaluation, the edge of the torn liver was

covered with an absorbable collagen sponge. The

operator washed the abdominal cavity, prepared a

drainage tube, and sutured the peritoneum and fascia. A

peritoneal tube was installed in the right abdomen equal

to the umbilical. Continues suture was performed at the

peritoneum and fascia with multifilament

nonabsorbable thread no 1. The subcutis was sutured

with simple interrupted using 2.0 multifilament

absorbable thread. Then the cutis was stitched with a

simple interrupted using 3.0 nonabsorbable

multifilament suture.

The wound in the right inguinal from the previous

hospital was opened. There is an irregular edge,

subcutis base, 10cm long, contaminants (+) iron rust +

peeling paint wound. Debridement was conducted using

H2O2 and betadine then washed with 0.9% NaCl infuse

until clean. The subcutis was closed with a simple

interrupted 2.0 multifilament absorbable thread. At the

last step, the cutis was done with a simple interrupted

3.0 nonabsorbable multifilament suture. Four bags of

packed red cells and four bags of whole blood were

fulfilled during the operation due to active bleeding.

The total estimated blood loss from the procedure was

800 ml.


30

Figure 4. Laparotomy exploration procedure followed by foreign body disposal and insert abdominal tube drainage

Postoperative routine hematology was carried out,

resulting in abnormal leukocytes (15.1 x 103). Chest

imaging demonstrated a lung contusion. The patient

was admitted to the ICU for recovery. Vital signs, urine

output, routine blood laboratory, drainage product from

both chest and abdomen tube measured every day. On

the first day, the chest and abdominal drainage

produced 50 ml and 200 ml sero-hemorrhage. After one

day of treatment in the ICU, leukocytes measurement

came back with normal value. On the third day

postoperative, the drainage production was stopped

from the chest drainage, while the drain from the

abdominal tube still produced 400 ml of bile.

The patient went to the standard care room. A PA

chest X-ray was conducted before the transfer to the

standard care room. The result showed a pulmonary

contusion, and then the chest drainage was removed.

The patient was discharged after seven days of

hospitalization. The abdominal drainage was persisted

with an average production of 50 ml per 24 hours. The

liver function enzymes were elevated (SGOT 104 and

SGPT 143). On the 12th day after the operation, a

follow-up was carried out with the patient's general

condition was good, the wound was clean, and there

were no signs of inflammation. Because the abdominal

drainage was not producing any secrete, it was

removed. Abdominal ultrasound was performed, which

resulted in a normal abdomen. The routine blood and

liver function test were back to the normal level.

DISCUSSION Penetrating trauma in the thorax-abdominal region

may lead to complicated and life-threatening conditions

(Shanmuganathan, K., & Matsumoto, J. 2006). Several

causes, such as high kinetic energy with large-caliber

firearms and low kinetic energy of stab wounds, can

result in penetrating injuries. Patients with stabbing

abdominal trauma should be evaluate signs of organ

failure, pneumothorax, and peritonitis based on physical

examination, laboratory, and radiology, including

ultrasound, CT scan, MRI, or X-rays (Hanna, W. C., &

Ferri, L. E. 2009).

Airway, breathing, and circulation disorders that

require immediate treatment can occur due to

penetrating trauma in the thorax-abdominal region.

Massive hemothorax or penetrating thoracic trauma in

poor condition should undergo resuscitative

thoracotomy (Sawhney, C. et al., 2009). Initial

radiology examinations such as an x-ray of the chest

and focused abdominal sonographic examination for

trauma (FAST) may discover the accumulation of the

blood, both in the abdominal and peritoneal cavity, also

in the pericardial sac (Petrowsky, H. et al., 2012; &

Kim, K. T., & Seo, P. W. 2016). Insertion of a tube into

the pleural cavity to drain air, blood, bile, pus, or other

fluids is called tube thoracostomy. Thoracostomy or

thoracoscopic procedure is indicated when the

mediastinum blood clot evacuation and hemorrhage

control are not achieved. Thoracotomy is indicated

when a large volume of bleeding (>1.500 mL) or

continued hemorrhage (>200 mL/hour) is present

(Chen, C. Y. et al., 2010; Troxler, Max. 2016; & Biffl,

W. L., & Moore, E. E. 2010).

From this case, we found that the patient had

shortness of breath caused by a hematothorax on the

right side with ongoing bleeding. A negative FAST

examination showed no damage, but a green iron fence

on the abdominal wall that penetrated the lung

diaphragm was shown on the x-ray findings. Following

the guidelines from the 2014 World Journal of Surgery,

the examination was continued with thoracoscopy

(Thiam, O. et al., 2016). If there is a rupture of the

diaphragm, then a thoracostomy should be performed,

followed by a laparotomy.


31

Figure 5. Concept of thoracoabdominal stab wounds treatment based on initial examination (Biffl, W. L., & Moore, E. E. 2010).

Urgent thoracotomy is needed in the emergency of

hemothorax. Emergency management should consider

many factors, including indications, clinical conditions,

trauma mechanism, and imaging findings. The

requirement for urgent thoracotomy was made based on

ATLS protocol (chest drainage product >1500 ml initial

or >200 ml/day, large un-evacuated clotted hemothorax

which can cause shortness of breath that leads to life-

threatening conditions and risk for cardiac tamponade,

massive air leak, incomplete lung expansion, significant

chest wall defect, injury of the major vessel,

esophageal, diaphragm, and cardiac (Mahoozi, H. R. et

al., 2016). Delayed thoracotomy in chest injury results

in late empyema, fibrothorax, and other morbidities.

Abdominal sonography and chest X-rays in thoracic

injury should be accomplished routinely, including in

these patients (Mahoozi, H. R. et al., 2016; & Mock, C.

(Ed.). 2004).

Proper placement of chest tube on hemothorax case

will remove excess fluid from the pleural cavity. The

tube must be in the midaxillary line or posteriorly of the

anterior lateral line in a supine position, generally

placed in the sixth or seventh intercostal space. To

prevent blood clot obstruction, larger-diameter tubes

have been used for suspected hemothorax cases (Chen,

C. Y. et al., 2010; Mahoozi, H. R. et al., 2016; &

Broderick, S., & Hemothorax, R. 2013). Newly

prospective analysis of chest tube size compared size

28F to 32F tubes with 36F to 40F tubes in 293 patients

at a level I trauma center. The results discovered no

difference in the outcomes for previously placed chest

tubes. Chest tubes removal was considered when the

drainage production is less than 150 ml/24 hours

(Muchuweti, D., & Muguti, E. 2020; & Mahoozi, H. R.

et al., 2016).

Figure 6: Algorithm for the diagnostic and therapeutic approach of hemothorax. (Mahoozi, H. R. et al., 2016)


32

The right thoracoabdominal incision has been

reported by Kim and Seo to gain access to the bleeding

source and treat injuries caused by a steel bar

penetrating the abdomen (Kim, K. T., & Seo, P. W.

2016). We gained access by performing simultaneous

thoracotomy followed by laparotomy. By widening the

operating area, the attempt to control bleeding became

easier. The definitive therapy for organ injury

management based on the severity of the injuries. From

this case, the hemothorax is caused by a direct

laceration to the chest blood vessels. Trauma to the lung

parenchymal from the thoracic wall penetration is

common and mostly self-limiting, although the injury

can result in occult hemopneumothorax. Chest imaging

and blood gas analysis were done during the patient

ICU admission to detect early complications and further

damage of the pulmonary parenchymal tissue. In this

patient, after the 12th day of postoperative control, there

was no sign of hemopneumothorax (Muchuweti, D., &

Muguti, E. 2020; & Kim, K. T., & Seo, P. W. 2016).

One of the causes of death in severe abdominal

injury is liver damage. It is responsible for 10% to 15%

mortality. The American Association for the Surgery of

Trauma (AAST) divided the severity of liver injuries

into six grading scales. Most patients admitted for liver

injuries have grade I, II, or III, and nonoperative

management are successfully treated. In contrast,

almost two-thirds of grade IV or V injuries require

laparotomy. In this case, the laceration of the liver is

more than 30% of the hepatic lobe. According to the

AAST liver trauma classification, this indicates a grade

IV liver injury that requires laparotomy (Todd, S. R.

2004). Intensive resuscitation during operation with

early institution of a massive transfusion protocol is

needed to preserve organ perfusion and reverse all

trauma-induced physiological derangements.

The WSES position paper classified traumatic

hepatic lesions into minor (grade I, II), moderate (grade

III), and major/severe (grade IV, V, VI). A laparotomy

surgery was performed based on the patient's clinical

condition. Patients with high-grade lesions (i.e., grade

IV-V laceration with parenchymal disruption involving

more than 75% of the hepatic lobe or more than 3

Couinaud segments within a single lobe) may treat

nonoperatively if the hemodynamic is stable. On the

other hand, “minor” lesions may need immediate

surgery when the patient arrives with hemodynamic

instability. Unstable conditions are described by the

systolic, mean arterial pressure < 65 mmHg dan blood

pressure is < 90 mmHg with clinical evidence of shock

with skin vasoconstriction (cool, clammy, decreased

capillary refill). Decrease level of consciousness and/or

shortness of breath, or > 90 mmHg but requiring

infusions/transfusions and/or vasopressor drugs and/or

admission base excess (BE) > -5 mmol/l or transfusion

requirement of at least > 4 units of packed red blood

cells within the first eight hours (Coccolini, F. et al.,

2016).

Based on the vital sign from this case, this patient

was in stable condition, but the ongoing bleeding could

be a life-threatening condition; thus, immediate

laparotomy should be performed. Based on WSES

classification, the patient had severe hepatic injuries

WSES grade III includes AAST-OIS grade IV–V

hemodynamically stable (Coccolini, F. et al., 2016).

The Pringle maneuver is a surgical technique for

abdominal operations that the hepatoduodenal ligament

is clamped with a surgical tool or by hand for a short

time. This maneuver is used during liver surgery to

reduce blood loss for a short duration. In this case,

using the Pringle maneuver followed by suturing the

wound and giving blood transfusions helped stabilize

the situation (Broderick, S., & Hemothorax, R. 2013; &

Coccolini, F. et al., 2016).

CONCLUSION

Management of thorax-abdominal trauma needs

contribution from a multidisciplinary discipline of the

medical team. A stab of the thoracoabdominal region is

associated with damage of organs, high morbidity, and

mortality. Life-threatening conditions require

immediate and appropriate thoracostomy and

laparostomy procedures to save the patient and prevent

long-term complications can be prevented early. The

best treatment approaches are made base on the clinical

condition, grade of injury, and the associated injuries.

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