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Penetrating trauma

Last updated: December 1, 2023

Summarytoggle arrow icon

Penetrating trauma is an injury caused by a foreign object piercing the skin, resulting in damage to underlying structures and an open wound. The most common types of penetrating injuries are gunshot wounds and stab wounds. Clinical features and diagnostic studies vary based on the type of penetrating trauma and the injured region of the body. The assessment of patients with penetrating trauma follows the systematic evaluation outlined in Advanced Trauma Life Support (ATLS): primary survey, transfer to a trauma center (if indicated), secondary survey, and tertiary survey. Management involves treating immediately life-threatening injuries and surgical repair of traumatic injuries.

See also “Management of trauma patients” and “Blunt trauma.”

Overviewtoggle arrow icon

Management of penetrating trauma is based on the type and location of the injury. Recommendations in this article are consistent with the 2018 ATLS algorithm. [1]

Stab wounds [1][2]

  • Epidemiology: ∼ 1500 people die from stab wounds annually in the US [3]
  • Mechanism of injury
    • Caused by the thrusting action of a pointed object (e.g., knife, broken bottle)
    • The depth of the injury is usually greater than the width.
    • Tissue is lacerated and torn along the path of the object.

Only remove impaled foreign bodies (e.g., knives) in settings where definitive hemostatic control is possible (e.g., operating room) as they might be tamponading injured blood vessels. [4]

Gunshot wounds (GSWs) [1][2]

  • Epidemiology
  • Mechanism of injury
    • Tissue is lacerated and crushed along the path of the bullet.
    • Tissue is displaced forward and radially, resulting in cavitation and pressure injury of nearby structures.
    • The level of injury is related to the kinetic energy of the bullet; energy varies based on factors such as bullet weight and velocity.
    • Dense organs (e.g., liver, bone) absorb more kinetic energy than less dense organs, resulting in greater injury.

Sites of penetrating trauma [1]

Penetrating chest traumatoggle arrow icon

Approach to penetrating chest trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Clinical features

Consider cardiac injury in patients with stab wounds to the cardiac box, i.e., a surface anatomy square bordered superiorly by the sternal notch, inferiorly by the xiphoid process, and laterally by the nipples. [7]

Diagnostics

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Do not delay treatment of clinically diagnosed tension pneumothorax to obtain radiologic confirmation. [1]

Treatment

Bedside interventions

Perform the following during the primary survey:

Urgent thoracotomy

Penetrating abdominal traumatoggle arrow icon

Approach to penetrating abdominal trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

In persistently unstable patients with indications for exploratory laparotomy during the primary survey, do not delay operative management (e.g., damage control surgery) for CT scanning. [1]

Clinical features [1]

Significant intraperitoneal injury occurs in ∼ 98% of abdominal gunshot wounds and ∼ 30% of abdominal stab wounds. [1]

Diagnostics [1]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Retroperitoneal injuries may be missed on DPL and FAST. [1]

If indicated, do not delay exploratory laparotomy to obtain CT scans. [1]

Exploratory laparotomy [1]

Conservative management [8]

Consider the following in consultation with the trauma team for select stable patients without indications for exploratory laparotomy:

Penetrating thoracoabdominal and flank traumatoggle arrow icon

Anatomic regions [1]

Injuries [1]

Management [1]

Maintain a high index of suspicion for diaphragmatic injury and retroperitoneal injury in patients with stab wounds or GSWs to the thoracoabdominal and/or flank regions.

Diaphragmatic injurytoggle arrow icon

Exercise caution when inserting a chest tube in patients with suspected diaphragm injuries to prevent injuring herniated abdominal structures. [1]

Penetrating neck traumatoggle arrow icon

Approach to penetrating neck trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Do not probe penetrating neck wounds as this can cause life-threatening bleeding.

Clinical features [2][13]

  • Penetrating neck wound
  • Impaled foreign body (e.g., knife)

Hard signs of penetrating neck injury [2]

The presence of any of the following increases the likelihood of life-threatening injury requiring surgical intervention often bypassing CT imaging:

Soft signs of penetrating neck injury

The presence of any of the following increases the likelihood of serious injury and often requires a CTA neck for further evaluation:

Any penetrating neck trauma that violates the platysma requires surgical consultation. [12]

Cervical collars can obscure injuries. Remove the cervical collar and maintain manual inline cervical stabilization while examining the patient.

Classification

The following zones of the neck were classically used to predict which underlying structures might be injured and to guide management, however, this is being supplanted by the 'no zone' approach, which focuses on identifying hard signs of penetrating neck injury plus CTA for stable patients to guide management. [12][13]

Diagnostics [2]

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Treatment [1][2][14]

Airway management [12]

Cricothyroidotomy may be impossible if anatomic landmarks are invisible or deformed, e.g., due to a laryngeal fracture. Emergency tracheostomy may be required for a failed intubation. [1]

Disposition [2]

  • Consult surgical subspecialties based on clinical and diagnostic findings.
  • Admit asymptomatic patients with no concerning findings on CTA for serial examinations for 24–36 hours.

Penetrating extremity traumatoggle arrow icon

Approach to penetrating extremity trauma [1]

Ensure the following components are included as part of the standard management of trauma patients using the ATLS algorithm:

Clinical features

Hard signs of extremity vascular injury [15]

Diagnostics

See “Urgent diagnostics for trauma patients” for a comprehensive approach.

Treatment

Consider any penetrating wound with a concomitant fracture an open fracture until proven otherwise. [1]

Disposition [16]

High-pressure injection injuriestoggle arrow icon

High-pressure injection injuries are surgical emergencies. The extent of the injury is often underestimated; extensive soft tissue loss can occur without prompt treatment.

  • Etiology: often results from working with or cleaning the nozzle of machines that spray fluids at high pressure (e.g., paint guns, grease guns, concrete injectors, diesel fuel jets) [17]
  • Clinical features
    • Small entrance wound
    • Often affects the nondominant hand
    • Early presentation: no symptoms or mild symptoms
    • Late presentation
      • Swelling, pallor, resting pain
      • Severe tenderness to palpation
      • Severe pain with passive motion
  • Imaging: Obtain x-rays of the extremity for all patients.
  • Initial management [2][17]
  • Definitive treatment
    • Most symptomatic patients: surgical exploration and debridement
    • Patients without symptoms several hours after injection with:
  • Complications

High-pressure injection injuries with organic solvents are considered surgical emergencies even if entrance wounds are small and the patient is asymptomatic at initial presentation. [2]

Referencestoggle arrow icon

  1. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  2. Nowicki J, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018; 100 (1): p.6-11.doi: 10.1308/rcsann.2017.0191 . | Open in Read by QxMD
  3. Shiroff AM, Gale SC, Martin ND, et al. Penetrating Neck Trauma: A Review of Management Strategies and Discussion of the ‘No Zone’ Approach. Am Surg. 2013; 79 (1): p.23-29.doi: 10.1177/000313481307900113 . | Open in Read by QxMD
  4. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  5. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association Critical Decisions in Trauma: Penetrating neck trauma. J Trauma Acute Care Surg. 2013; 75 (6): p.936-940.doi: 10.1097/ta.0b013e31829e20e3 . | Open in Read by QxMD
  6. Como JJ, Bokhari F, Chiu WC, et al. Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma. Journal of Trauma: Injury, Infection & Critical Care. 2010; 68 (3): p.721-733.doi: 10.1097/ta.0b013e3181cf7d07 . | Open in Read by QxMD
  7. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJF, Scalea TM. Penetrating Torso Trauma: Triple-Contrast Helical CT in Peritoneal Violation and Organ Injury—A Prospective Study in 200 Patients. Radiology. 2004; 231 (3): p.775-784.doi: 10.1148/radiol.2313030126 . | Open in Read by QxMD
  8. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis.. Am J Surg. 2015; 209 (5): p.864-8; discussion 868-9.doi: 10.1016/j.amjsurg.2014.12.023 . | Open in Read by QxMD
  9. McDonald AA, Robinson BRH, Alarcon L, et al. Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018; 85 (1): p.198-207.doi: 10.1097/ta.0000000000001924 . | Open in Read by QxMD
  10. Manthey DE, Nicks BA. Penetrating Trauma to the Extremity. J Emerg Med. 2008; 34 (2): p.187-193.doi: 10.1016/j.jemermed.2007.03.038 . | Open in Read by QxMD
  11. Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma. J Trauma. 2012; 73 (5): p.S315-S320.doi: 10.1097/ta.0b013e31827018e4 . | Open in Read by QxMD
  12. Kim JS, Inaba K, de Leon LA, et al. Penetrating injury to the cardiac box. J Trauma Acute Care Surg. 2020; 89 (3): p.482-487.doi: 10.1097/ta.0000000000002808 . | Open in Read by QxMD
  13. Harms J, Bush M. A Comparative Analysis of Knife and Firearm Homicides in the United States. J Interpers Violence. 2022; 37 (19-20): p.NP17886-NP17910.doi: 10.1177/08862605211029620 . | Open in Read by QxMD
  14. Thomson BNJ, Knight SR. Bilateral Thoracoabdominal Impalement: Avoiding Pitfalls in the Management of Impalement Injuries. J Trauma. 2000; 49 (6): p.1135-1137.doi: 10.1097/00005373-200012000-00029 . | Open in Read by QxMD
  15. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015; 79: p.5-14.doi: 10.1016/j.ypmed.2015.06.002 . | Open in Read by QxMD
  16. Wintemute GJ. The Epidemiology of Firearm Violence in the Twenty-First Century United States. Annu Rev Public Health. 2015; 36 (1): p.5-19.doi: 10.1146/annurev-publhealth-031914-122535 . | Open in Read by QxMD
  17. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018

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