Management of a massive thoracoabdominal impalement: a case report
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LETTER TO THE EDITOR Open Access Management of a massive thoracoabdominal impalement: a case report Haider Abbas Dear Sir, With great interest, I read the case report of Manage- ment of a massive thoracoabdominal impalement (SJTREM,2009, 17:50 (7 October 2009)[1]. The topic is interesting but the position of patient decided by the authors could have been modified so that the airway management, anaesthesia and surgery could have been made more conventional, convenient, speedy and less cumbersome. Trauma remains a leading cause of death across all age groups, some of the injuries are dynamic and it is crucial for the Anaesthetists to have upto date under- standing of Injury patterns, mechanisms, and pathophy- siology to facilitate optimal management of these patients[2] because in some cases of thoracic Impale- ment Injuries chances of survival[3] are high. Early deaths are secondary to hypoxemia, airway obstruction, hemorrhage, haemothorax, cardiac tamponade and aspiration. In this published case report the impaled iron angle was projecting in the anterior-posterior direction and the patient and iron angle were supported at all times and the authors decided to intubate the patient in semi- reclining position supported all the time by helpers, anesthetist stood on the stool to gain additional height and even left thoraco-abdominal incision needed to be given instead of conventional midline or paramedian Incision. Peroperative management is very challenging in such cases and the position of patient is very crucial for the safe conduct of such cases. One of the options available is to place the patient in lateral position[4]. Different authors have described the use of fibreoptic intubation is sitting position[5]. This technique has limited value in emergency situations and may require more time than conventional laryngoscopy. Position of the patient can be modified in such cases for safe peroperative management of patients. Operation theatre tables are composed of different attachments so that various positions(trendelenberg, anti-trendelenberg, sitting, lateral) can be made for different procedures. I am of the view that in this case the patient could have been placed in the supine postion after transfer from the ward with some additional help from the theatre staff by using gap (Figure 1) in the theatre table attach- ments where the Impaled rod can be placed and Correspondence: [email protected] Department of Anaesthesiology, CSM Medical University, Lucknow, India Figure 1 Operation Theatre Table Top. Still Image showing operation theatre table top with gap between the table attachments. Abbas Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:57 http://www.sjtrem.com/content/18/1/57 © 2010 Abbas; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Transcript of Management of a massive thoracoabdominal impalement: a case report
LETTER TO THE EDITOR Open Access
Management of a massive thoracoabdominalimpalement: a case reportHaider Abbas
Dear Sir,With great interest, I read the case report of Manage-
ment of a massive thoracoabdominal impalement(SJTREM,2009, 17:50 (7 October 2009)[1]. The topic isinteresting but the position of patient decided by theauthors could have been modified so that the airwaymanagement, anaesthesia and surgery could have beenmade more conventional, convenient, speedy and lesscumbersome.Trauma remains a leading cause of death across all
age groups, some of the injuries are dynamic and it iscrucial for the Anaesthetists to have upto date under-standing of Injury patterns, mechanisms, and pathophy-siology to facilitate optimal management of thesepatients[2] because in some cases of thoracic Impale-ment Injuries chances of survival[3] are high. Earlydeaths are secondary to hypoxemia, airway obstruction,hemorrhage, haemothorax, cardiac tamponade andaspiration.In this published case report the impaled iron angle
was projecting in the anterior-posterior direction andthe patient and iron angle were supported at all timesand the authors decided to intubate the patient in semi-reclining position supported all the time by helpers,anesthetist stood on the stool to gain additional heightand even left thoraco-abdominal incision needed to begiven instead of conventional midline or paramedianIncision.Peroperative management is very challenging in such
cases and the position of patient is very crucial for thesafe conduct of such cases. One of the options availableis to place the patient in lateral position[4]. Differentauthors have described the use of fibreoptic intubationis sitting position[5]. This technique has limited value inemergency situations and may require more time thanconventional laryngoscopy.
Position of the patient can be modified in such casesfor safe peroperative management of patients. Operationtheatre tables are composed of different attachments sothat various positions(trendelenberg, anti-trendelenberg,sitting, lateral) can be made for different procedures. Iam of the view that in this case the patient could havebeen placed in the supine postion after transfer fromthe ward with some additional help from the theatrestaff by using gap (Figure 1) in the theatre table attach-ments where the Impaled rod can be placed and
Correspondence: [email protected] of Anaesthesiology, CSM Medical University, Lucknow, India
Figure 1 Operation Theatre Table Top. Still Image showingoperation theatre table top with gap between the tableattachments.
Abbas Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:57http://www.sjtrem.com/content/18/1/57
© 2010 Abbas; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.
peroperative management can be done in more conven-tional, convenient and speedy manner (Figure 2).To summarize, the management of massive thoraco-
abdominal impalement injuries can be made simpler bymodifying the position of patient by making use of gapsin the theatre table attachments and placing the patientin conventional supine postion.
AbbreviationsSJTREM: (Scandinavian Journal of Trauma, Resuscitation and EmergencyMedicine)
AcknowledgementsNone
Competing interestsThe author declares that they have no competing interests.
Received: 13 September 2010 Accepted: 26 October 2010Published: 26 October 2010
References1. Sawhney C, D’souza N, Mishra B, Gupta B, Das S: Management of a
massive thoracoabdominal impalement:a case report, ScandinavianJournal of Trauma. Resuscitation and Emergency Medicine 2009, 17:50, (7October 2009).
2. Moloney JT, Fowler SJ, Chang W: Anesthetic management of thoracictrauma. Curr Opin Anaesthesiol 2008, 21(1):41-6.
3. Robicsek F, Daugherty HK, Stansfield AV: Massive chest trauma due toimpalement. J Thorac Cardiovasc Surg 1984, 87(4):634-6.
4. Prasad MK, Sinha AK, Bhadani UK, Chabra B, Rani K, Srava B: Managementof difficult airway in penetrating cervical spine injury. 2010, 54(1):59-61.
5. Lai YY, Chien JT, Huang SJ: Fiberoptic intubation with patients in sittingposition. Acta Anaesthesiol Taiwan 2007, 45(3):169-73.
doi:10.1186/1757-7241-18-57Cite this article as: Abbas: Management of a massive thoracoabdominalimpalement: a case report. Scandinavian Journal of Trauma, Resuscitationand Emergency Medicine 2010 18:57.
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Figure 2 Line diagram showing the patient and theanaesthetist’s positions during Intubation. The anaesthetist isstanding on the floor while intubating the patient who is lyingsupine on the table with penetrated rod (passing through thethoraco-abdominal region) placed in the gap between the tableattachments of the operation theatre table.
Abbas Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:57http://www.sjtrem.com/content/18/1/57
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