Penetrating injury

ETIOLOGY:
  • Penetrating trauma can be caused by a foreign object or by fragments of a broken bone.
  • Penetrating injuries are commonly caused by gunshots and stabbings
SIGNS & SYMPTOMS:
HEAD & NECK:
  • Head
  1. While penetrating head trauma accounts for only a small percentage of all traumatic brain injuries, it is associated with a high mortality rate
  2. Penetrating head trauma can cause cerebral contusions and lacerations, intracranial hematomas, pseudoaneurysms, and arteriovenous fistulas.
  • Neck
  1. Penetrating neck trauma involves a gun shot or sharp object (stab, puncture wound & impalement injuries) penetrating the skin and volating the platysma layer of neck
  2. Esophageal injury shows odynophagia, subcutaneous or mediastinal emphysema, pleural effusion, air in the retro-esophageal space and unexplained fever
  • Eye
  1. Sympathetic opthalmitis is a bilateral granulomatous (non-suppurative/plastic) panuveitis which almost always follows penetrating wound in the ciliary region (danger zone) with incarceration of ciliary body, iris (uveal tissue & vitreous) or lens capsule 
CHEST
  • Penetrating chest trauma can injure vital organs such as the heart and lungs and can interfere with breathing and circulation.
  • Lung injuries that can be caused by penetrating trauma include 
  1. pulmonary laceration
  2. pulmonary contusion
  3. emothorax
  4. pneumothorax
  5. hemopneumothorax
  • Commonest cause of death in penetrating injury of chest is Tracheobronchial injury
  • When the heart is punctured, it may bleed profusely into the chest cavity if the membrane around it (the pericardium) is significantly torn, or it may cause pericardial tamponade if the pericardium is not disrupted.
ABDOMEN:
  • PAT can be life-threatening because abdominal organs, can bleed profusely, and the space can hold a large volume of blood.
  • Injuries of the liver, common because of the size and location of the organ, present a serious risk for shock
  • The intestines, taking a large part of the lower abdomen, are also at high risk of perforation.
  • Signs of hypovolemic shock and peritonitis 
  • Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause bruits 
  • Percussion of the abdomen may reveal hyperresonance or dullness
  • The abdomen may be distended or tender, signs which indicate an urgent need for surgery.
DIAGNOSIS:
  • X-ray and CT scanning may be used to identify the type and location of potentially lethal injuries. 
  • Sometimes before an X-ray is performed on a person with penetrating trauma from a projectile, a paper clip is taped over entry and exit wounds to show their location on the film. 
  • Barium swallow is diagnostic in neck injury
MANAGEMENT:
  • The patient is given intravenous fluids to replace lost blood.
  • Surgery may be required; impaled objects are secured into place so that they do not move and cause further injury, and they are removed in an operating room.
  • Foreign bodies such as bullets may be removed, but they may also be left in place if the surgery necessary to get them out would cause more damage than would leaving them.
  • Wounds are debrided to remove tissue that cannot survive and other material that presents risk for infection
Exam Question
  • Penetrating injury to neck is defined as Violation of platysma
  • Sympathetic ophthalmitis results due to Penetrating injury of ciliary body
  • Esophageal injury is Most common after penetrating injury
  • Esophageal injury Can lead to mediastinal collection
  • Barium swallow is diagnostic of esophageal injury
  • Organ most commonly damaged in penetrating injury of abdomen is Liver & Small intestine
  • Commonest cause of death in penetrating injury of chest is Tracheobronchial injury

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