Thoracic impalement injuries are uncommon among civilians. When it occurs, it´s usually a severe and dramatic form of chest injury that requires immediate operative intervention. The common mechanisms usually encountered involves either a patient falling from a height onto a pole, being driven into a pole following ejection during a road traffic accident or being impaled when a spear/an arrow is thrown at the patient or from long fragments following a blast. Impalement by a retrograde ejected barrel of a gun during recoil is a very uncommon mechanism. We report 2 recently managed patients. The first patient presented with an overt impaling mass and an initially missed tension pneumothorax. The second patient had a covert impalement chest injury. Both patients had surgical interventions with satisfactory outcomes. Our report aims to highlight this unusual mechanism of thoracic impalement injury and the principles of management. We also want to emphasize the importance of adhering to the advanced trauma life support (ATLS) management algorithm, as immediately life-threatening conditions may be missed when exploratory thoracotomy is the only focus.
Empyema thoracis is defined as the presence of pus in the pleural space or a purulent pleural effusion. Chronic empyema is characterized by thickened visceral and parietal peels, which hamper the ability of the affected lung to re-expand and require definitive surgical intervention. In a resource constraint environment like ours, open thoracotomy and decortication is the treatment of choice. We review our experience with cases of chronic empyema thoracis that had thoracotomy and decortication. This is a descriptive, retrospective, and observational study. Medical records of patients who had thoracotomy and decortication on account of chronic empyema thoracis in the Cardiothoracic surgery unit of our hospital between 2012 and 2020 were retrieved and reviewed. The information obtained from the records included sex, age, premorbid conditions, aetiology of empyema, cultures of pleural fluids, histology results of the cortex removed, duration of chest tube drainage, duration of hospital stay, postoperative complications, and outcome. One hundred and eighty-five patients diagnosed with empyema thoracis were seen in the study period. Sixty-five patients had thoracotomy and decortication on account of chronic empyema thoracis while the remaining 120 (64.9%) had closed tube thoracostomy drain insertion. Male: female was 5:1, mean age at presentation 24.24 years with age ranging from 2 years to 70 years. Fourteen (23.33%) were in the paediatric age group while the remaining (76.67%) were adults. The aetiology of empyema was pneumonia in 36 (60%). Strept pneumoniae was the commonest organism isolated from pleural fluids of these patients accounting for 23.33%. All patients underwent thoracotomy and decortication. The mean duration before surgery was 17 days with a range of 2 days to 40 days. The average duration of surgery was 2 hours. Chest tube was removed after an average of 7 days (range 5 to 33 days. Twenty-one patients (35%) had complications. The average duration of drainage was 18.87 days and that of hospital stay was 36.74 days. There were 3 mortalities (5%). The mean duration of follow-up was 3 months. Chronic empyema thoracis is still common in our environment and presentation is usually very late. In our series, open thoracotomy and decortication was found to be an excellent procedure with low morbidity and mortality. The majority of our patients had good functional outcome with few complications.
Chylothorax is defined as accumulation of chyle in the pleural space. Various aetiologies have been identified.Direct injury to the thoracic duct following gunshot injury is rare. When it occurs close to the point of entry into the confluence of the internal jugular and subclavian veins, it can lead to massive chylothorax with devastating consequences. A case of gunshot to the root of the neck with massive chylothorax with haemodynamic instability is hereby presented.
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