ABSTRACT

CORRESPONDING AUTHOR:
Dr. Sanjay Sharma,
Assistant Professor,
Department Of General Surgery,
S.P.Medical College, Tel : IV-E-225,    .  
JNV  Colony,Bikaner-334003, Rajasthan, INDIA.
E-mail: drsanju13@rediffmail.com

ABSTRACT:  Penetrating chest and abdominal injuries are potential life threatening due to the associated haemorrhagic shock and visceral injury 1,2. Through and through penetrating injury with poly trauma is rarely encountered 8. We report a case presenting with situ projecting heavy iron- metallic rod in a through and through penetrating into left arm and thoraco-abdomen in a road traffic accident.
Management was difficult due to inability to position in supine, rapidly progressive haemorrhagic shock and hypoxia due to haemo pneumothorax. Two operative tables were used with adequate intervening space to accommodate the projecting rod during intubation in supine position. Delayed development of thrombosis in brachial artery after removal of iron rod, which was removed and brachial artery was repaired. Intensive monitoring and resuscitation resulted in uneventful outcome.
KEYWORDS-Heavy Iron rod, Brachial artery, Thrombus, Penetrating injury, Thoraco-Abdomen.

INTRODUCTION: Penetrating wounds represent 25% of all urban traumas which include gunshot, and stab wounds. These injuries are potentially life threatening and often warrant exploration3,9. Penetrating wounds presenting with in situ objects are rarely encountered, and anaesthetic and surgical management is complex due to inability in positioning the patient and the risk of sudden haemorrhage. The management of these types of injuries is challenging with respect to airway control, urgency for the surgery, positioning of the patient on operation table and associated hemodynamic instability1,2,9. We report the management of a patient, who presented with through and through penetrating injury by 20mm. heavy iron rod through the Left Arm and Thoraco-Abdomen with an intact penetrating object projecting posteriorly. Positioning for intubation, resuscitation and surgery was extremely challenging, due to late development of thrombosis in brachial artery, fracture of last two ribs and difficult intubation.

CASE REPORT: A 30-year-old male patient was brought to the casualty department with an in situ 20.mm heavy metallic rod projecting over the back in a through and through penetrating the arm and Thoraco-Abdomen following road traffic accident. The entry and exit wounds were in the left arm and chest (left side to the midline), respectively [Figures1&2]. The penetrating heavy metallic bar had to be cut prior to transporting the patient to the hospital.
Mode of Injury- A 30-year-old milk man, when he was passing near construction work riding his motor bike. Two workers were shifting the iron rod along the road side  and patient was talking on cell phone (while driving) with his left hand so his left arm comes nearer to chest on left side, iron rod pierced through and through the left arm and left side of the  chest and exited from back.( Figure-3)
      The patient presented with acute dyspnoea, numbness and chest pain. He was in hypovolemic shock and tachycardia. Auscultation revealed decreased air entry in the left thorax with oxygen saturation on room air of 80%. Oxygen supplementation (8 L/minute) with face mask and intravenous fluids were started. The patient was extremely restless, chest radiograph revealed left-sided pneumothorax. Intercostal drainage tube (ICDT) was planned but insertion was difficult owing to difficulty in positioning the restless patient. The patient was rushed immediately to operation theatre in a lateral position. He was positioned supine over two operating tables arranged in parallel such that the metallic rod was positioned in between them. ICDT was placed in the left 4th intercostal space and simultaneously anaesthesia was induced with intravenous ketamine 100 mg. Succinylcholine 75 mg i.v. was administered and modified rapid sequence tracheal intubation was performed.. Volume replacement with colloids and crystalloids to maintain intra-operative blood pressures.. Two and a half litres of crystalloids, one units of whole blood were replaced. The patient was repositioned semi-laterally so as to visualize both ends of the iron rod which was then accessed and removed by lateral thoracotomy-extending up to lateral flank. Approach revealed retro pleural haematoma, last two ribs fracture and exposure of Pre-Renal fat and Fascia, after removal of chest part of the rod by applying incision over it ( Fig-4)  
      The arm was assessed for vascularity by radial pulse and nail bed filling was sluggish, wound enlarged longitudinally and neurovascular status was assessed under vision ,neural sheath of median nerve found damaged but fibres were intact  and after removal of iron rod  thrombus was noticed in brachial artery which was removed by thrombo-embolectomy and artery repaired with distal circulation restored. The all procedure took about 2 hrs. Postoperatively, the patient was mechanically ventilated for 36 hours ,and was extubated, once haemodynamically stable. The patient was discharged from the hospital on the 15th day after removal of stitches.

DISCUSSION: Although penetrating injuries of chest and abdomen are common, Penetrating injury by heavy iron rod pierced into arm and through thoraco-abdomen is rare.  Various types of Objects causing such injury include glass, knife, barbed wire, plank, forklift, broomstick and metal hooks. Survival following a through and through penetrating thoraco-abdominal injury with a large heavy iron rod is rare when associated with polytrauma4,6,7. Difficulties in managing such a patient are manifold due to hypoxia, hemorrhagic shock, urgency of surgical intervention and inability to position the patient supine and late development of thrombus 4.
 Airway control may be challenging if the projecting object in the back precludes supine positioning and any inadvertent manipulation can result in sudden collapse of the patient. Resuscitation and close monitoring prior to and during surgery5,9, especially at the time of removal of penetrating object, is vital with anticipation of major vascular injuries. There was delay in reaching the hospital as the penetrated metallic rod had to be cut by electric cutter from the both end at road side.
     Progressive dyspnoea, due to penetration from arm to chest wall and projecting from both ends (arm and chest wall) Chest injury with fracture ribs mandated emergency ICDT insertion to relieve hemo-pneumothorax. ICDT insertion was required prior to anaesthesia in emergency department due to hemothorax and dyspnoea; however this was not possible due to inability to position the patient on the table due to rod and progressive restlessness of patient.
Positioning to administer anaesthesia was difficult. Tracheal intubation with the patient in lateral position was not practical as the long metal bar was projecting and there was associated chest injury, arm injury and simultaneously fracture ribs. To position the patient supine without disturbing the projecting metal rod on the back, a “two-table technique” was used. Two parallel tables were arranged and patient was positioned in such a way that the projecting rod passed between the two. Endotracheal intubation fortunately could be performed without difficulty. This “two-table technique” is a safe and simple solution for this life-threatening situation with projecting objects over back of chest and abdomen.
 Brachial artery thrombus developed at the site of the penetration after removal of the rod during surgery. The thrombus was removed and artery repaired. Serious arterial and venous bleeding may be encountered while removing the object from the chest wall (inferior vena cava, aorta injury) one should be prepared for this outcome. Preoperative angiography, giving large incision at the suspected site of vascular injury ,no pulling the object blindly, removal should be done under vision. This avoids avulsing of nerve and vessels.
Thrombosis developed after removal of penetrating rod which was developed by diminished radial artery pulsations and extremity developed cyanosis. The thromboembolectomy was done and vessel repaired. Recovery was prompt and postoperative period was uneventful.
Hypovolemia was partly corrected; Modified rapid sequence induction-intubation with ketamine in this circumstance may be the choice. ICDT tube was in place for the pneumothorax. Dopamine infusion was started along with volume replacement to maintain adequate blood pressure and organ perfusion. Volume replacement was done with blood, and crystalloids transfusion. Advanced trauma life support (ATLS) curriculum advocates rapid infusion of up to 2 L of warmed isotonic crystalloid solution for any hypovolemic, to restore normal BP and urine output. 100% oxygen was used as the patient was in shock.
      The patient was treated by broad-spectrum antibiotics and weaned from mechanical ventilation after 36 hours. He was then discharged from ICU and admitted to the ordinary ward, after which he had uneventful recovery and was discharged from the hospital in good general condition.

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Figure-1, Penetrating 20.mm heavy metallic bar projecting over the back in a through and through penetrating the arm and chest . (In operation theatre)

Fig-2, Penetrating 20.mm. heavy metallic bar projecting over the left arm. (In operation theatre)