Traumatic hemothorax and hemoperitoneumdue to penetration by a single missile:Report of a case of thoracoabdominal injury

THOMAS FRANCIS A. POWELL, D.O.Philadelphia, Pennsylvania

Wounds and Injuries

The management of thoracoabdominalpenetrating injuries isextremely important in viewof the life-threatening potential of suchwounds and their increasingfrequency as a result of urban violence.Early exploration is essentialbecause of rapid deterioration in thepatient's condition and thepossibility of injury to multiple organs.Penetration of the leftdiaphragm creates considerable risk.If the thorax at or below the fourthinterspace is involved,abdominal involvement should besuspected immediately.The intrathoracic wounds shouldreceive first priority intreatment by tube thoracostomy orthoracotomy. Separateincision is required when the abdominalcavity also has to beentered. A case report involving agunshot wound in thechest illustrates some of the problemsinvolved. The bullet puncturedthe anterior and posterior chest wall,lacerated the left lungand diaphragm, and created a largehole in the spleen; therewas considerable hemorrhage. Thepatient survived afterthoracotomy, splenectomy, and carefulhematologic management.

Since the beginning of recorded history, violentwounds have been inflicted by men againsttheir own kind. There are three cases of pene-trating thoracic wounds in the Edwin SmithPapyrus recorded between 2500 and 3000 B.C.'Betts2 defined a thoracoabdominal injury asone in which an instrument or missile hasentered or traversed both the pleural and theperitoneal space and perforated the diaphragmas a result. If separate foreign bodies haveentered the two cavities without diaphragmaticperforation, then the injuries should be termedcombined thoracic and abdominal injuries, hestated. Because of increasing urban violenceinvolving guns, thoracoabdominal penetratingwounds are frequently encountered in theemergency rooms of the nation's urban hos-pitals. According to Shefts, 3 '4 who summarizedthe basic principles of treating thoracic woundson the basis of extensive experience in WorldWar II, these wounds require "more finesse inmanagement than almost any other type ofinjury."

Experience in the treatment of penetratingwounds of the thorax during wartime3 -6 hasresulted in a significant reduction in mortality,from 44 percent in World War I to 6 percentin the Korean war. Mastro6 said :

The mortality arising from thoracoabdominal injuries,omitting the factor of mortality from associatedwounds, is directly dependent upon, not only the num-ber of organs involved, but the particular organ in-volved. Hence, the mortality rate may vary from 16 to40%.

Reyes and Reyes7 reported 20 percent deathsin their series of 134 cases, but stated that themortality rate was 5.6 percent when the liveralone was injured but 52.6 percent when theliver and other organs were involved.

The knowledge gained from military experi-ence has been used advantageously in the treat-ment of civilian injuries. However, successful

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treatment still has to be based on the funda-mental principles of anatomy and the complexphysiology of the chest and its viscera. Of im-mediate importance are resuscitation after theshock of injury and associated blood loss andrestoration of cardiorespiratory dynamics asnear to normal as possible.

The most serious aspect of thoracoabdominalwounds is the damage to the deeper structures.Even a small external wound may be associatedwith considerable internal damage. Adams8stated that in evaluations of the extent of dam-age it is important to determine as accuratelyas possible the extent of the internal injuryon the basis of the course of the missile. Thismay be estimated by comparing the wound ofentrance with the wound of exit, if there isone, or by roentgenologic localization of theintrathoracic missile. Nealon8 said that usuallythe missile will travel by a straight line withinthe body, unless it is fragmented or impededby bony structures. For this reason, recon-struction of the line of travel between woundsof entrance and exit will permit a fair ap-praisal of the tissues involved.8

Penetrating missile wounds involving thethorax at or below the fourth interspace imme-diately should be suspected of involving theabdomen. In general, exploration should becarried out as soon as conditions permit forall thoracoabdominal penetrating injuries.Beall and associates" reported that in theirconsiderable experience with penetrating in-juries laparotomy with intercostal tube tho-racostomy was successful in a high percentageof cases regardless of whether the penetratingchest wound was associated with demonstrableintrathoracic injury. They used this procedurebecause significant intrathoracic injury maygo undetected until after induction of positivepressure and the start of laparotomy, whentension pneumothorax and shock become mani-fest.

The critical survival time after injury ap-pears to be 2 hours, according to Reyes andReyes.? If the patient survives for 2 hours, hischances for survival thereafter are increasedconsiderably.

It is obvious that the more extensive anintra-abdominal injury is, the greater is the

hazard. With rare exceptions an intrathoracicwound should be treated first when a patienthas thoracoabdominal injuries. Snyder & re-ported that 15 consecutive deaths of patientswith combined thoracic and abdominal injuriesoccurred when celiotomy was done before chestsurgery.

Indications for thoracotomy, according toBeall and associates," include "continuinghemorrhage, recurrent pericardial tamponade,chest wall repair, persistent or uncontrollableair leak, and known or suspected esophagealinjury." It is well known that continuinghemorrhage from parenchymatous injuries ofthe lung is rare unless a hilar structure orsystemic vessel is involved.

When the left diaphragm is penetrated, thereis considerably more hazard than when theright side is affected. Penetration of the leftdiaphragm, according to Shefts, 4 is an unques-tionable indication for surgery, but similarinvolvement on the right side is only a relativeindication. By no means do all liver injuriesrequire surgery, and many more ruptures andlacerations probably pass unnoticed than arefound. Injuries can occur singly or together tothe liver, spleen, kidney, and large and smallbowel with penetration of the left side of thediaphragm (Fig. 1).

In closed thoracoabdominal injuries, whichusually result from high-speed auto accidents,many organs may be ruptured by the suddendeceleration.8 Such accidents may occur inareas where facilities for total care of suchinjuries may be lacking. Military experiencehas shown that after initial resuscitative mea-sures have been carried out, transfer to a well-equipped facility is not contraindicated.4

It is essential to close intestinal perforationsto prevent death from peritonitis, and to stophemorrhage from splenic laceration by splenec-tomy. Thoracoabdominal incisions generallyare not used. Instead, separate thoracic andabdominal incisions are employed when boththe chest and the abdominal cavity have to beentered.8,7,9," This approach reduces the pos-sibility of contamination and infection, espe-cially when exteriorization of the colon has tobe carried out.

The following case of thoracoabdominal

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1 LUNG2 DIAPHRAM3 LIVER(left lobe)4 STOMACH5 COLON(splenic flex)6 SPLEEN"(KIDNEY (left)

penetration via the left side of the diaphragmillustrates some of the problems associatedwith such injuries.

Report of caseA 24-year-old Negro woman was admitted tothe emergency room at PCOM Hospital at ap-proximately 10 p.m. She had been shot in thechest at approximately 9 :45 p.m. All she couldrecall was that she was walking down the streetwhen the shooting occurred. Her personal his-tory included a possible disorder of blood coagu-lation. Her mother stated that she had bled for3 weeks after a tooth extraction 6 months priorto admission. She had had no significant opera-tions except for a dilation and curettage severalyears before. She was allergic to penicillin,sulfonamides, tomatoes, and peaches. She hadno history of ear, nose, or throat disease. Shereported constipation and irregular, prolongedmenses. Her family history was not remark-able. On physical examination her blood pres-sure was 80/50 mm. Hg, her pulse rate 100 perminute, and respirations 24 per minute. Therewas no abnormality of ears, nose, or throat.

Examination of the thorax showed punctureof the left anterior chest wall at the fifth in-terspace, and puncture of the posterior chestwall at approximately the eighth interspace.The heart rate was regular at 100 per minute,the lungs clear, and the abdomen normal. Pel-vic examination was not done.

Administration of Ringer's lactated solutionwas begun at from 80 to 100 drops per minute,and the patient was taken to the x-ray de-partment by litter. A chest film showed noevidence of pulmonary or pleural abnormalityor of displacement of the heart or mediastinum.After admission, she was taken to the surgicalfloor, and orders were written for blood typingand cross matching of 5,000 ml. of whole blood,1,000 ml. of 5 percent glucose and Ringer'ssolution, 1,000 ml. of 5 percent glucose andNormosol-R, 0.5 cc. of tetanus toxoid, and oxy-gen by nasal catheter. Instructions were giventhat if the pulse rose above 110 or the systolicblood pressure fell below 80, the attendingsurgeon should be notified. Determinations ofhemoglobin and hematocrit were to be madeevery 4 hours.

Fig. 1. Path of trajectory in case report indicated byarrow. Other possible organ involvement with leftthoraco-abdominal penetrating wounds is indicated bythe second line.

The patient was given 0.5 mg. of Araminesolution intramuscularly immediately on ad-mission, because of a slight drop in blood pres-sure during transport to the x-ray departmentby litter.

At admission her blood showed 12 gramshemoglobin, 200 mg. sugar during fasting,and 7 mg./100 ml. of urea nitrogen. Her hema-tocrit reading was 39 percent.

She reached the surgical floor at 11 p.m.and was checked by the attending surgeon, thehouse physician, and a senior student. At about2 a.m. her blood pressure dropped to 70/40mm. Hg, and the pulse rate increased. Herhemoglobin was 7 grams, her white cell count30,000, and her hematocrit reading 25 percentat this time.

She was taken to the operating room andplaced on the table. The blood pressure wasnot discernible, and the heart beat was faint.The anesthesiologist could not detect bloodpressure or pulse prior to the start of anes-thesia. The patient was subjected to a thora-cotomy, which revealed 1,500 ml. of blood inthe thoracic cavity as a result of laceration ofthe inferior lobe of the left lung. Lacerationof the diaphragm also was present and showedentrance and exit with disruption of a bloodvessel within the diaphragm. This was bleedingfreely. The laceration of the diaphragm was

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closed with interrupted sutures and that ofthe lung with a running suture. The thoracot-omy incision was closed after insertion of thethoracotomy tube. Then the abdomen wasopened by a midline incision from the um-bilicus to the xiphoid process. Approximately2,000 ml. of blood was present in the abdominalcavity, and there was a large hole in the spleencaused by the projectile. Splenectomy wasdone, and the blood in the abdominal cavitywas aspirated. The operation was completed,and the patient was returned to her room inpoor condition.

She had been given 2,000 ml. of blood inthe operating room and was given 1,000 ml.also at the time she was evaluated on the floor.Aramine 25 mg., Vasoxyl 20 mg., and Solu-Medrol 200 mg. in clysis also had been given inthe operating room. She was given packed cellsafter surgery.

Instructions were given for attaching thethoracotomy tube to an underwater seal bottle,and phlebitis boots were ordered. Intermittentpositive pressure breathing with saline solutionwas to be started in 48 hours. She was givenregular insulin based on periodic testing ofher urine for sugar and acetone every 4 hours,and intravenous administration of Keflin, 4grams every 12 hours, was prescribed. Hema-tologic consultation was requested, and oxygengiven by nasal catheter. The patient's condi-tion was relatively stable the following morn-ing. She was given 1,000 ml. of Ringer's solu-tion, 1,000 ml. of Normosol-R, and 1,000 ml.of lonosol, intravenously. Her hemoglobin wasapproximately 9 grams and her hematocritreading 32 percent. She was given another1,000 ml. of blood, which boosted her hemo-globin to 13.1 grams and hematocrit to 42percent.

She was maintained on intravenous fluids for3 days because of diminished bowel sounds, andthen this was discontinued. She was givenVibramycin orally, and the Keflin was discon-tinued.

Her postoperative course was relatively un-eventful. The electrocardiogram the day fol-lowing surgery showed sinus tachycardia. Thiswas interpreted as either a racial characteristicor the result of myocardial injury. Subsequent

electrocardiograms were normal.A roentgenogram 48 hours after surgery

showed pleural effusion in the left basal area,with upper limits at the seventh interspaceat the left lateral aspect of the thorax and im-paired ventilation of the apical segment of theright upper lobe. Sharp angulation of thethoracotomy tube also was seen. The tube waspulled back a little, and this was satisfactory.An x-ray film 2 days later showed completereventilation of the apical segment of the rightupper lobe and elevation of the left hemidia-phragm. Pleural effusion could not be seen atthis time. The interstitial components of theleft lower lobe were somewhat modified, un-doubtedly as a result of the antecedent surgeryand the pleural effusion that had been pre-viously seen.

The patient was discharged in good conditionon the twelfth postoperative day. At that timethe hemoglobin was 13.1 grams and the hema-tocrit 42 percent. She was scheduled to bechecked in the outpatient clinic. The pathol-ogist's report gave as the diagnosis lacerationof the spleen, with hemorrhage, due to a gun-shot wound.

X-ray study of the chest 6 weeks postop-eratively showed no abnormality.

CommentThe case reported illustrates some of theproblems associated with thoracoabdominal in-juries involving penetration of the left hemi-diaphragm.

Because of rapid deterioration and thepossibility of injury of multiple organs, ex-ploration should be carried out as soon aspossible.

Intrathoracic wounds should receive firstpriority in management either by tube thora-costomy or by thoracotomy, depending on cir-cumstances. Thoracoabdominal incisions gen-erally are not advisable. The critical point forsurvival appears to be 2 hours after injury.

Although many thoracoabdominal injuriesare hopeless from the beginning, especiallywhen major wounds involve the heart andgreat vessels, no patient who reaches the emer-gency room alive should be allowed to die fromprogressive hemorrhage or perforation of ab-

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8. Adams, H.D.: Thoracic injuries. Surg Clin North Ara 41:619-39,Jun 619. Nealon, T.F., Jr.: Trauma to the chest. In Surgery of thechest, edited by J.H. Gibbon, D.C. Sabiston, and F.C. Spencer.W.B. Saunders Co., Philadelphia, 196910. Beall, A.C., Jr., et al.: Surgical management of penetratingthoracic trauma. Dis Chest 49:568-77, Jun 66

dominal viscera without temporary manage-ment until transfer to a well-equipped institu-tion or direct surgical intervention is possible.

Appreciation is expressed to Thomas Moy, D.O., andGalen Young, Jr., D.O., whose valuable assistance madepossible the recovery of the patient.

1. Breasted, J.H.: Edwin Smith Papyrus, Vol. 1. University ofChicago Press, Chicago, 19802. Betts, R.H.: Thoraco-abdominal injuries. A report of twenty-nine operated cases. Ann Surg 122:793-806, Nov 453. Shefts, L.M.: The initial management of thoracic and thoraco-abdominal trauma. Charles C Thomas, Springfield, 19564. Shefts, L.M.: Thoraco-abdominal injuries. Am J Surg 105:490-500, Apr 635. Snyder, H.E.: The management of intrathoracic and thoraco-abdominal wounds in the combat zone. Ann Surg 122:333-57, Sep 456. Mastro, E.R.: Management of thoracoabdominal wounds. Acase report. Med Bull US Army Europe 20:335-6, Nov 637. Reyes, A.I., and Reyes. D.A.: Thoraco-abdominal injuries. Areview of 134 cases. Int Surg 46:582-8. Dec GG

Dr. Powell is a lecturer in the Depart-ment of Physiology and Pharmacologyat the Philadelphia College of Osteo-pathic Medicine and is an associate inthe Department of Surgery at PCOMand Metropolitan Hospitals.

Dr. Powell. 5725 Lansdowne Ave., Phi:-adelphia 19131.

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