Penetrating Trauma - Causes, Treatment, and Complications

Introduction

Penetrating trauma occurs due to applying direct, sharp force to the body, injuring the deep tissues and creating an open wound. Since most of these injuries are of gunshot or stabbing type, they are violent and come under the list of criminal cases. It causes serious injuries and is associated with several complications due to the open wound. The severity and the extent of the injury should be well assessed for a proper treatment protocol.

What Is Penetrating Trauma?

A penetrating trauma occurs when a sharp object pierces the body. In contrast, blunt trauma is an injury that is caused by a dull object or due to a blunt force. Penetrating injuries mostly result in the object entering and exiting the body, creating an open injury. Sometimes, the object may still be there when the patient reports to the hospital. A thorough assessment of the velocity, size of the object, and direction of the injury helps manage the affected patients effectively.

How Does a Penetrating Injury Occur?

A penetrating injury occurs through the use of knives, swords, firearms (guns), animal attacks, or impalements (a method of execution wherein the body is pierced with a long and sharp tool). Out of these, the most common are gunshots and stab wounds.

Gunshot Wounds: They can be intentional or unintentional. Intentional gunshots include cases of suicide or homicide (murder). Unintentional gunshots include hunting or while cleaning the gun where the person is shot unknowingly.

• The usual handguns are of medium velocity, whereas rifles and other military weapons are of higher velocity, which results in greater internal damage. Low-velocity injury includes the use of knives and produces minimal injury.
• When a bullet is fired from a gun, it causes a hole in the body cavity, and due to its compression, the tissues around it also get damaged subsequently.
• In organs like the bone and liver, they absorb more energy and hence suffer from a higher intensity of the injury. Lungs, on the other hand, absorb less energy and suffer from less injury.
• A bullet does not follow a straight path. Hence, multiple injuries would have occurred along the path of the bullet.

Stab Wounds: Stabbing is also intentional or unintentional. Intentional stabbing includes suicide or homicide. An unintentional stabbing refers to unknowingly landing or falling on a sharp object that gets pierced through the body.

• Instruments like knives, daggers (like a larger knife used as a fighting weapon), glass pieces, or any other sharp object produce a stab wound.
• Stabbing follows a straight path, but the depth of penetration would be more. The stab to the chest and the abdomen should be more deeply examined as the diaphragm (a muscle below the lungs used in respiration) between the two structures may get damaged. A stab wound at this part of the body causes pain, shortness of breath, and cough.

How to Assess a Patient With Penetrating Trauma?

Any trauma patients must undergo ABC resuscitation, which includes airway, breathing, and circulation. The specific treatment for the injury is done only after a detailed assessment of the basic parameters of the patient.

1. Airway:

The airway assessment is started by listening to the air movement and the chest wall movement. Any block in the airway is indicated with the stridor (loud breathing sound) and has to be managed immediately.

• Any injuries to the spine are noted, and the spine is immobilized.
• The quality of breathing, spontaneous breathing, and skin color are noted.
• If there are any secretions being drained away from the wound, a suction tube is placed.
• A jaw thrust wherein the lower jaw is held using the fingers of both hands, and upward and forward pressure is applied. This helps to relieve airway obstruction.

2. Breathing:

The quality of breathing, spontaneous breathing, and skin color are noted.

• If the skin color changes to bluish, it indicates decreased supply of oxygenated blood to that part.
• The oxygen saturation of the patient is noted and must be maintained in the range of 94-98%. If the value is lower, oxygen is administered to the patient using a bag valve mask for proper ventilation.
• The respiratory rate and oxygen saturation are continuously monitored.

3. Circulation:

• The pulse is recorded at different areas of the body to check their rate and rhythm. The most important areas are those near the neck, thigh, and elbow.
• Check if the patient is conscious and responds to the questions asked.
• Any presence of bleeding must be controlled.
• If the circulation is impaired, immediate CPR (cardiopulmonary resuscitation) is administered to the patient. CPR is a life-saving procedure wherein the two hands of the rescuer are placed on the patient’s chest and are pushed fifteen times, followed by one mouth-to-mouth breath. This cycle is repeated again. It is usually performed by a trained doctor or even a normal person if they know the correct procedure to save the patient.

After assessing the above parameters, the response and the movement of the limbs are also checked. A detailed history of the injury, allergy and medical history are recorded. All the patient's belongings, including the clothes, are packed in a separate bag as it might be required during the investigation. Since most penetrating injuries are intentional, evidence collection of the penetrating objects and other things remains important.

How to Treat a Patient With Penetrating Trauma?

The treatment for the patient with an open wound depends on which body part is affected. The trauma can be in any area, but the trauma to the chest and the abdomen necessitates emergency treatment as they hold some of the vital organs in the body.

In cases of penetrating chest trauma, the patient may suffer from the following complications:

• Tension Pneumothorax- It is the entrapment of air in the pleural space (space between the lungs and the chest wall). This inhibits the air inflow to the lungs and leads to the compression of the other lung. A patient with such a condition has absent breath sound on the affected side, shortness of breath, and an extended chest. A needle is placed into the pleural space to equalize the pressure and relieve the lung compression. A permanent treatment for the condition is by placing a thoracostomy tube (a thin plastic tube to drain out air or fluid from the chest) into the pleural space to remove the excess air inside.
• Open Pneumothorax- It is the entrapment of air between the lungs and the chest when the air flows through the open wound into the body. When the patient breathes, the air is sucked through the open wound, and a sucking sound can be heard. The patient will have reduced breath sounds and difficulty breathing. For these patients, an air and water-tight dressing is placed over the open wound and secured with bandages. This helps to prevent the air from entering the open wound.
• Cardiac Tamponade- It is the pooling of blood or fluid in the space between the heart and its outer wall. A thoracostomy can be done to remove the fluid or an autotransfusion device that collects, filters, and reinfuses the blood is used.

In penetrating abdominal injuries, the extent of injury depends on what object is used to pierce the body. Patients present with bleeding, infection, and injury to the blood vessels and organs. The abdomen may get distended. Bleeding and contamination have to be controlled to prevent any further complications.

It is important to note that any patient injured by a sharp object is admitted without taking the object out of the body. X-rays are taken with the object inside, and after a thorough examination, the object is removed carefully during the operation without damaging the adjacent structures. Emergency procedures are first done. Then surgical exploration is done under an operatory setup. Close monitoring of the vitals and recording them regularly helps to check and maintain the progress of the patient.

What Are the Possible Complications After Penetrating Trauma?

Since the patient has undergone violent trauma with an open wound, the most common complication is sepsis. Sepsis is the spread of infection all over the body and has to be managed immediately. Other complications include infection due to the open wound or massive bleeding.

Conclusion

Penetrating trauma can be a minor or life-threatening injury to the body, depending on the depth of the injury and the organs involved. Death from these types of trauma is common if there is a severe injury to an organ, delayed hospital admission, or complications arise that lead to the early death of the patient even before starting the treatment. If the patient is admitted to the hospital within a few hours after the incident and has a minor injury that is treatable, emergency procedures and appropriate treatment is followed to improve the patient’s progress and save their life.