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Home , Penetrating trauma

Journal of Surgical Sciences (2018) Vol. 22(1) @ 2012 Society of Surgeons of Bangladesh

JOURNAL OF SURGICAL SCIENCES

Case Report AND CAUSED BY PENETRATING CHEST 2 4 K.A.B.M Talful Alam1, Md. Shah Alam Sarker , Md. Khaled Hasan3, Prawesh Maharjan

Abstract Pneumothorax and pneumoperitoneum caused by penetrating are rare. Pneumo• following trauma usually indicates the presence of a perforated intraabdominal hollow viscous. Other causes of pneumoperitoneum are through the abdominal wall, through the diaphragm, through female genital tract and through retroperitoneum. Here we report an unusual case of pneumothorax and pneumoperitoneum caused by penetrat• ing injury in the posterior aspect of chest in a young male patient of 33 years who presented to us with chest & & breathlessness. The diagnosis was made on clinical & radio• logical examination. Tube thoracostomy was done followed by and repair of diaphragmatic & . Post operative recovery was uneventful & the patient was discharged on 9th p.o.d after removal of thoracostomy tube & stiches.

Keywords: Pneumothorax, Pneumoperitoneum, Thoracostomy,Laparotomy. Introduction of the mediastinum or change in the hemi The chest serves the important functions of respira• diaphragm. tion & of protection of the vital intrathoracic & upper Pneumoperitoneum following trauma usually abdominal organs from externally applied force and is indicates the presence of a perforated intraabdomi• composed of the rigid structure of the rib cage, nal hollow viscous and the need for laparotomy2. clavicles, sternum, scapulae & heavy overlying Other causes of pneumoperitoneum are through the musculature. Penetrating chest are generally abdominal wall, through the diaphragm, through 3 less common but more deadly than blunt chest injury. female genital tract and through retroperitoneum • Approximately 10%-14% of penetrating chest injuries Here we present a case of penetrating chest injury require emergency surgery' i.e. thoracotomy. where left lung, left dome of diaphragm and spleen Pneumothorax is a common complication of penetrat• are injured causing pneumothorax and pneumoperi• ing thoracic trauma. It results from free air into the toneum. pleural cavity. There are three types of pneumothorax. The purpose of this issue is to provide awareness Simple, communicating or open and tension pneumo• about abdominal visceral injury which may be undiag• thorax. Simple pneumothorax does not result in shift nosed due to upper thoracic injury.

1. Associate Professor, Department of Surgery, 4. Intern Doctor, Department of Surgery, Jahurul Jahurul Islam Medical College, Bajitpur, Kishore• Islam Medical College & Hospital, Bajitpur, ganj. Kishoreganj. 2. Registrar, Department of Surgery, Jahurul Islam Medical College & Hospital, Bajitpur, Kishoreganj. Correspondence to: Dr. K.A.B.M Taiful Alam, Associ• 3. Assistant Registrar, Department of Surgery, ate Professor, Department of Surgery, Jahurul Islam Jahurul Islam Medical College & Hospital, Bajitpur, Medical College, Bajitpur, Kishoreganj. Phone: Kishoreganj. 01716836678 E-mail: [email protected]

PAGE-67 Pneumothorax and pneumoperitoneum caused by penetrating chest injury K.A.B.M Taiful Alam et al Case Report X-ray chest revealed pneumoperitoneum with left A 33 years old male patient was assaulted and sided pneumothorax and basal consolidation. But no stabbed by his cousin with a pointed rod to the back bony lesion was detected. Trachea was central & of the chest. He was brought to the emergency there was no mediastinal shifting. department of Jahurul Islam Medical College Hospital CT of and chest showed pneumoperito• after approximately 12 hours of injury. Before that he neum and left sided pneumothorax, bilateral pleural was treated conservatively and had a stitch on his effusion and basal consolidation. Abdominal Ultraso• wound at another hospital. During admission he had nography demonstrated left sided pleural effusion. pain in the chest and abdomen with breathlessness. The Laboratory examination was unremarkable The patient looked anxious and his BP was 110/80 except for polymorphonuclear leucocytosis. mm of Hg, Pulse rate 90/min, respiratory rate was After patient was taken to the operation 30/min and his temperature was high. theatre where under general anaesthesia with endo• A thorough physical examination revealed there was a tube thoracostomy was done on penetrating injury in the back of the left chest near the left side by placing a 40 French chest tube. At the inferior angle of scapula which was about 1cm in laparotomy, grade-1 injury in the spleen and a small diameter, tenderness was found around the wound perforation in the left hemi diaphragm were but no active was detected. There was no detected. crepitus or . Diaphramatic injury was repaired and splenorrhaphy was done. Abdomen was closed in layers keeping a drain in situ. The patient's vital signs, abdominal and thoracic conditions were monitored daily and the collection in the chest and abdominal drains were observed. The patient was improved gradually uneventfully and the abdominal drain was removed on the 4th POD. On 7th POD control chest x-ray was done and chest drain was removed and patient was discharged on 9th POD after removal of the abdomi• nal and chest wound stitches.

Discussion Penetrating thoracic injury is potentially serious. Site of Penetration of rod Site of Penetration of rod Some of the common injury pattern observed includes chest wall injuries, pneumo and hydrothorax, pulmonary laceration, , tracheo• bronchial injuries, cardiac injuries, diaphragmatic injuries, oesophageal injuries, injury to the great vessels and injury to the abdominal viscous". Among these pneumo and are particu• larly common and intercostal chest tube placement is the most common intervention. If the initial bleeding through the chest tube is Thoracoabdominal CT showing Pneumothorax & 1500ml or 200mljhour for 2-4 hours, then emer• Pneumoperitoneum gency thoracotomy should be considered". The cause of pneumoperitoneum and the clinical Examination of the respiratory system showed move• signs determine its mode of treatment- surgical or ment of the chest was reduced on the left side. There not. When sign, symptoms of acute abdomen (local was hyper resonance in the left side with diminished , pyrexia, leucocytosis) are present, surgical breath sound. management is mandatory. But in case of non surgi• Examination of abdomen found it was distended, cal pneumoperitoneum with mild symptoms and there was rigidity and tenderness in the abdomen and without any sign of peritonitis, conservative treatment 6 obliteration of dullness was detected. is indicated •

PAGE-68 Vol. 22 No. 1 January 2018 Journal of Surgical Sciences Recently laparoscopic exploration instead of References laparotomy can be the operation of choice in cases of 1. Meredith JW, Hoth JJ. Thoracic Trauma: When & how pneumoperitoneum because it can both determine to intervene. Surg clin North AM 2007; 87:95-118 and treat the cause offering all the advantages of 2. Di Saverios, Filicori F, Kawamukai K, et al, combined minimally invasive surgery'. pneumothorax and pneumoperitoneum following Most of the diaphragmatic injuries are occult when .Post graduate medical journal- associated with but there is 2011;87:75-78 potential for late herniation8 resulting pulmonary 3. Mularski RA, Sippel JM, Osborne ML, Pneumoperito• compromise or strangulation of abdominal contents neum: a review of non surgical causes. Crit care Med 5 2000;28:2638-44. and includes a mortality rate of up to 36% • 4. Mei L, Ozcelik C, Tacyildig I, et al. Penetrating chest As the x-rays are non specific for diagnosis of injuries, world J surgery 1998 may 22(5):438-42. diaphragmatic injury, a missed diaphragmatic injury 5. Working group, Ad hoc subcommittee on advanced and subsequent morbidity can be minimised by trauma life support, American College of surgeons immediate laparotomy for all patients with abdominal -Committee on Trauma, Thoracic Trauma. In; or low thoracic penetrating injury. Advanced Trauma life support for Doctors, 8th ed. The surgical approach to the diaphragmatic injuries is Chicago: American College of Surgeons; 2008:85- individualized. Acute left sided injuries are best 101 approached through abdomen. Acute right sided 6. Karaman A, Demicbilek S, Akin M, Gurunluoglu K, injuries and all chronic injuries should be approached lrisi C; Does pneumoperitoneum always require 9 through the chest . laparotomy? Report of six cases and review of the Another option for diagnosis of diaphragmatic injury is literature pediatric surgery int 2005,21;819-824. video assisted thoracoscopic surgery". 7. Michail Piliakoudis, Petros Zegos, Anastasia Oikono mou, Michail Kirmanidis, Georgias Kouklakis; Spontaneous idiopathic pneumoperitoneum Conclusion presenting ass an acute abdomen; a case report. Penetrating chest injury causing pulmonary, diaphrag• Journal of medical case reports.2011,5:86. matic and abdominal visceral injury is uncommon. 8. Degiannia E, et al. Diaphragmatuc herniation after Pneumoperitoneum in the absence of hollow viscous penetrating trauma. Br J Surg 1996;83:88-91. perforation is also uncommon and even rarer when 9. Reynolds MA, Richardson JD, Chest wall and caused by low impact traumatic pneumothorax diaphragmatic injuries, Maull KL, Rodriguez A, without concomitant . A thorough WilesCE Ill, eds. Complications in trauma and critical physical examination and laboratory and radiological care. Philadelphia, PA; WB Saunders;1996:313- findings are useful tools for surgical intervention or 324 conservative management. 10. Cases SR, Richardson JD. Role of thoracoscopy in acute management of chest injury. Curr Opin Crit Case.2006 Dec,12(6):584-9.

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