Management of Severe Thoracic Impalement Trauma Against Two-Wheeled Horse Carriage: A Case Report and Literature Review

Abstract

Thoracic injuries in general are of great importance due to their high incidence and high mortality. Thoracic impalement injuries are rare but severe due to the combination of cause, effect and result. This study's primary objective is to report the case of a young man who was impaled by a two-wheeled horse carriage shaft while crashing his motorcycle in a rural zone. An EMT-B ferry was called at the crash scene and a conscious patient was found, sustaining a severe impalement injury to the left hemithorax, suspended over the floor by the axial skeleton with the carriage shaft coming across his left chest. As a secondary objective, a literature review of thoracic impalement injuries is performed. Cases of thoracic impalement injury require unique and individualized care based on injury severity and affected organs. Reported protocols for managing impalement injuries are entirely anecdotal, with no uniformity on impaled patient's approach and management. In penetrating trauma, it is essential not to remove the impaled object, so that possible vascular lesions remain buffered by the object, avoiding major bleeding and exsanguination haemorrhage. Severed impaled thoracic patients should be transferred to a specialist centre for trauma care, as these lesions typically require complex multidisciplinary treatment. High-energy thoracic impalement injuries are rare and hold a high mortality rate, due to the complexity of trauma and associated injuries such as thoracic wall and lung lesions. Modern medicine still seems limited in cases of such seriousness, not always with satisfactory results.

WSES position paper on vascular emergency surgery

“…In thoracic penetrating injuries, the trajectory of the projectile or of the blunt object is the key to determine the anatomic structures involved. In general, missile trajectories that pass through the midline are at more risk for significant vascular injuries [ 36 , 37 ].…”

A rare case of a transabdominal impalement after a fall from a ladder

“…The most important rule in the prehospital management is not to remove the impaled object [3] , [4] , [9] . An assumption of the tamponade effect of an impaling arrow on the surrounding blood vessels was already made by Bill JH back in 1862 [11] .…”

Penetrating abdomino-thoracic injury with an iron rod: An anaesthetic challenge

“…Removal should only be attempted on OT under anaesthesia when arrangement to explore the patient is complete because the foreign body in situ may generate a plugging effect on the injured vessels or structure, thus preventing major bleeding. [ 3 4 8 ]…”