A client is admitted to the emergency department with a stab wound of the chest
by Rie Aihara, M.D. and Wayne LaMorte, M.D., Ph.D., M.P.H. A 17 year-old male from Michigan was visiting his cousins and friends in Boston, when he became a victim of a stabbing. This all began when the victim confronted an old friend about a personal conflict which occurred between them
years ago. What started out as a verbal argument eventually resulted in physical violence. The victim sustained a single stab wound to the left chest in the mid axillary line, just below the level of the nipple. He was transported to our emergency department by Boston EMS. He was noted to be awake and alert throughout the entire transport. Past Medical/Surgical History: Asthma The patient was moved from the stretcher onto the examination table, and the only complaint obtained from the patient was shortness of breath. Cardiac monitors, blood pressure-cuff and oxygen saturation probes were then placed on the patient. Heart rate- 90/min Primary Survey:Airway- patent airway as demonstrated by his ability to talk.
Circulation – no active external bleeding Radiological Survey:Chest X-ray: left sided hemopneumothorax
Other Pertinent Studies:Transthoracic Echocardiogram: no pericardial effusion
Blood Work Ordered:
Blood typing is essential because the patient may need transfusions and possibly surgery. The coagulation panel and CBC will be helpful as baseline and to see if other factors such as plasma may be required. Note that the hematocrit is not going to reflect the amount of bleeding this patient may have because the hematocrit is a percentage of red blood cells in the blood. When a trauma victim bleeds, the shed blood is whole blood (both red cells and plasma) which has the same hematocrit as the intravascular blood. It is only after the movement of interstitial fluid into the vascular space in an attempt to increase the total volume does the hematocrit drop from dilution. The arterial blood gas is an important indicator of blood loss, therefore hypoperfusion, resulting in metabolic acidosis (decreased bicarbonate). ER Procedures:Chest tube placement: drained 300cc of frank blood Change in status:The patient at this time began complaining of a new subscapular pain, or pain between the shoulder blades. This was alarming to the trauma team for the following reasons.
Operating Room:The surgical team performed a diagnostic laparoscopy in order to determine whether or not the diaphragm had been penetrated. The laparoscopy demonstrated an obvious defect in the diaphragm, as shown here. Inspection within the abdomen demonstrated blood clots on the anterior surface of the stomach and the left lateral segment of the liver. In order to more carefully assess the extent of intra-abdominal injuries and carry out repair, the procedure was converted to an open laparotomy. Upon exploration, there were three lacerations on the surface of the liver which required suture closure. There was also a 2 cm perforation of the anterior surface of the stomach which was closed primarily in two layers. In order to assess the extent of intrathoracic injuries more closely, the laparoscope was advanced from the abdomen into the thorax through the diaphragmatic defect. Examination of the pericardium showed no evidence of bleeding, contusion, or penetration. We therefore proceeded to close the diaphragmatic perforation with interrupted Ethibond suture with pledgets. Upon completion of the procedure the patient recovered without complications and was discharged to home in four days. Major Teaching Points:
Surgical exploration can be undertaken in one of two ways: a) the conventional approach is to perform an open laparotomy, and b) the alternate approach is to do a diagnostic laparoscopy. The primary purpose of the laparoscopy is to determine the presence of diaphragmatic perforation. If the diaphragm is intact, then there should be no intra-abdominal injuries. In this case, a midline incision can be avoided, and the recovery period will be shortened significantly. This can be beneficial to high risk patients such as those with pulmonary disease, cardiac disease and morbid obesity where a long midline incision can be a source of morbidity such as infection and respiratory compromise Share this: |