Blast- Multiple Penetrating Injuries
A 32-year-old male soldier sustained a severe blast injury with a chest wound and a supraclavicular wound, a tangential right shoulder wound, and right hand wounds. He arrives at the hospital for care. He was awake and alert, hemodynamically normal. A secondary survey revealed these wounds.
Injury Pattern
What are the possible injuries based on this wounding pattern?
Intra-thoracic (cardiac, pulmonary), great vessels/ right subclavian vessels
Next steps in evaluation?
Extended FAST exam to evaluate for fluid in chest, abdomen, and pericardial space.
CXR to identify for retained foreign body. Helpful to place radio-opaque markers on wounds to help establish trajectory.
Plain film of chest/ upper abdomen
What additional injuries are possible based on these wounds and imaging?
Any organ in the path of the wounds can be injured- this includes intra-abdominal structures (small and large bowel, stomach, spleen, kidney), retroperitoneal structures (kidney) and the diaphragm.
How do we determine which body cavity to explore first?
Hemodynamic stability and wounding pattern can direct how to proceed. A hemodynamically unstable patient requires swift intervention concurrent with ongoing resuscitation, while a stable patient can be approached more deliberately. The clinical exam can suggest which body cavity is causing the instability. Peritonitis, abdominal distension, grossly positive FAST in the abdominal views suggest the abdomen as the site of injury. Signs of thoracic injury causing instability include decreased breath sounds, jugular vein distension, muffled heart sounds, fluid on pericardial view of the FAST fluid, and a large volume of bloody output in the chest tube. In addition, location of projectiles on plain film help determine trajectory, and any structures along the trajectory can be injured.
This patient was managed in a deployed environment by an austere surgical team. We did not have access to CT imaging and we had limited capacity for continuous monitoring.
Therefore, in order to rule-out cardiac and intra-abdominal injuries, we performed a midline laparotomy. We performed a pericardial window through the laparotomy. There was no fluid in the pericardium. We performed an abdominal exploration. There were no intra-abdominal injuries.
Wounds in the Cardiac Box
In the classic description, the “cardiac box” is bordered superiorly and inferiorly by the sternal notch and the xiphoid process, and laterally by the nipples. However, thoracic gunshot wounds outside these confines can just as readily result in a cardiac injury.
The diagnosis of cardiac injuries starts with a physical exam and FAST. Physical exam findings can include hemodynamic instability, muffled heart sounds, and jugular venous distension (Beck's triad). FAST will reveal pericardial fluid.
If the patient is awake, they may be panicked and have an impending sense of doom.
Penetrating cardiac injuries require operative repair.
FAST Examination