Case presentation : Penetrating injury with a retained broken blade in the Left chest
Pt’s info :
A 25 years old Saudi male, with a previous Pulmonary Tuberculosis presented to our
emergency department with a retained broken blade in the left chest after being stabbed
from the back. There was no hemoptysis, hypotension, distended neck veins, or tracheal
deviation.
Physical Examination, Stability, Vitals:
On physical examination, the patient was conscious, alert, and oriented, with a patent
airway and a GCS of 15/15. Breath sounds were diminished on the left side. Vital signs
showed mild tachypnea (respiratory rate 22) and mild tachycardia (heart rate 109), but blood
pressure was normal (118/74) and oxygen saturation was 95% on room air. Upon inspection
of the wound, (more info needed here, specifically the close inspection and examination of
the wound)
Labs and Imaging :
The initial labs included blood gases which showed a mild metabolic acidosis with a PH of
7.21, lactate of 1.7 and a base deficit of -5.4. His baseline hemoglobin was 11.8 gm/dl. The
extended FAST showed a left hemopneumothorax, which was later confirmed with a chest
X-Ray that also showed a foreign body in the left chest and left surgical emphysema. A left
intercostal tube was inserted and drained approximately 400 ml of blood. As the patient
was hemodynamically stable, a contrast chest CT was performed and showed a hyper
dense object entering from the posterior upper medial aspect of the back between the
second and third ribs down to the lung parenchyma, the tip of the object was behind the
fourth rib antero-laterally. It also showed left mild hemopneumothorax with multiple lung
contusions and left chest wall surgical emphysema. No extravasation of the contrast was
noted, and the vascular structures alongside the airway were intact.
Operating Room Course :
The patient was taken to the operating room for emergency left posterolateral thoracotomy,
removal of blade, and proceed. The patient was under general anesthesia with a double
lumen ET tube. The anesthesiologist secured an arterial line, central venous line, and an
epidural catheter. The patient was in a right lateral decubitus position with proper padding
to the elbows and knees. The skin incision was marked with a marking pen, and performed
one finger below the scapular inferior angle, extending from the point located 5 to 6
centimetres lateral to the med spinal line all the way to the mid-axillary line following the
course of the underlying rib. With correct positioning, the tip of the scapula should face the
sixth rib. The initial incision was made and was deepened using an electrocautery going
through the subcutaneous tissue and superficial fascia until the fascia of the latissimus dorsi
and trapezius muscles were exposed. Then the serratus anterior and rhomboid muscles
were also exposed and then the serratus muscle was elevated and retracted anteriorly to
avoid its transaction. After the pleural space was entered, the finochietto retractor was
inserted and opened slowly to minimize the risk of re-fracture. Then the base of the blade
from the broken knife located by direct visualization and proper wound extension in the
upper lobe of the left lung. The base of the knife was grabbed and pulled out successfully,
then the wound was approximated along the edges. Clots were removed and the chest was
washed. Only then was the chest examined to rule out any other injuries. Two chest tubes
size 32 were inserted then the ribs were used to further approximate the wound and closure
was done layer by layer. ( Here we need more details from the OR note)
Post-op Events and Complication:
Progression and outcomes:
Imaging and Labs Afterwards
Post OP OPD