Penetrating chest wounds
Depending on their size, penetrating chest wounds may cause varying degrees of damage to bones, soft tissue, blood vessels, and nerves. Mortality and morbidity from such wounds depend on the wound’s size and severity. Gunshot wounds are usually more serious than stab wounds because they cause more severe wounds with rapid blood loss. Ricochet within a gunshot wound commonly damages large areas and multiple organs. Despite prompt, aggressive treatment, up to 90% of patients with penetrating chest wounds die.
Causes and incidence
Stab wounds from a knife or an ice pick are the most common penetrating chest wounds; gunshot wounds are a close second. Wartime explosions or firearms fired at close range are the usual sources of large, gaping wounds.
Penetrating chest injuries cause one in every four deaths in the United States. Many patients with this type of injury die after reaching the hospital.
Signs and symptoms
In addition to the obvious chest injuries, penetrating chest wounds can also cause:
❑ a sucking sound as the diaphragm contracts and air enters the chest cavity through the opening in the chest wall
❑ tachycardia due to anxiety and blood loss
❑ weak, thready pulse due to massive blood loss and hypovolemic shock
❑ varying levels of consciousness, depending on the injury’s extent. If the patient is awake and alert, the severe pain will make him splint his respirations, thereby reducing his vital capacity.
Penetrating chest wounds may also cause lung lacerations (bleeding and substantial air leakage through the chest wall), arterial lacerations (loss of more than 100 ml blood/hour through the chest tube), exsanguination, pneumothorax (air in pleural space causes loss of negative intrathoracic pressure and lung collapse), tension pneumothorax (intrapleural air accumulation causes potentially fatal mediastinal shift), and hemothorax. Other effects may include arrhythmias, cardiac tamponade, mediastinitis, subcutaneous emphysema, esophageal perforation, bronchopleural fistula, and tracheobronchial, abdominal, or diaphragmatic injuries.
Diagnosis
CONFIRMING DIAGNOSIS An obvious chest wound and a sucking sound during breathing confirm the diagnosis of a penetrating chest wound. Consider any lower thoracic chest injury a thoracoabdominal injury until proven otherwise.
Baseline tests include:
❑ pulse oximetry and arterial blood gas analysis to assess respiratory status
❑ chest X-rays before and after chest tube placement to evaluate the injury and tube placement; however, in an emergency, don’t wait for chest X-ray results before inserting the chest tube
❑ complete blood count, including hemoglobin (Hb) level, hematocrit (HCT), and differential (low Hb level and HCT reflect severe blood loss; in early blood loss, these values may be normal)
❑ palpation and auscultation of the chest and abdomen to evaluate damage to adjacent organs and structures.
Treatment
Penetrating chest wounds require immediate support of respiration and circulation, prompt surgical repair, and measures to prevent complications.
Special considerations
❑ Immediately assess airway, breathing, and circulation. Establish a patent airway, support ventilation, and monitor pulses frequently.
❑ Place an occlusive dressing over the sucking wound. Monitor for signs of tension pneumothorax (respiratory distress, tachycardia, tachypnea, and diminished or absent breath sounds on the affected side [tracheal shift]); if tension pneumothorax develops, temporarily remove the occlusive dressing to create a simple pneumothorax.
❑ Control blood loss (remember to look under the patient to estimate loss), type and crossmatch blood, and replace blood and fluids as necessary.
❑ Assist with chest X-ray and placement of chest tubes (using water-seal drainage) to re-establish intrathoracic pressure and to drain blood in a hemothorax. A second X-ray will evaluate the position of tubes and their function.
❑ Emergency surgery may be needed to repair the damage caused by the wound.
❑ Throughout treatment, monitor central venous pressure and blood pressure to detect hypovolemia, and assess vital signs. Provide analgesics as appropriate. Tetanus and antibiotic prophylaxis may be necessary.
❑ Reassure the patient, especially if he’s been the victim of a violent crime. Report the incident to the police in accordance with local laws. Help contact the patient’s family and offer them reassurance as well.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Chest symptoms
Read excerpts from these other book chapters related to Chest symptoms:
Medical Books Excerpts
- CHEST PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Chest pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Chest Pain
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Chest pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Barrel chest
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Chest pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Chest pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Chest Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Chest symptoms
» Next page: Chest expansion, asymmetrical (Professional Guide to Signs & Symptoms (Fifth Edition))
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