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Wed Sep 16 11:20:54 BST 2009

Dear Ross, dear Rob,

thank you for your answers.

So far the patient has been managed with tube thoracostomy and has  
been admitted for observation. The abdomen remains soft and non  
tender,  so there is not much concern about a possible hollow organ  
injury.

I was mostly wondering if, given the localization of the stab wounds,  
there was a need to surgically explore the left diaphragm to rule out  
a diaphragmatic laceration. If the answer is yes, what is the best  
approach to do so: thoraco or laparoscopy?

Anyone has an idea about the risk of subsequent diaphragmatic  
herniation for undiagnosed diaphragmatic injury? I've read that in  
case of gastric or colonic herniation the mortality is quite high,  
ranging from 20 to 50%.

On 16 Sep 2009, at 11:35, Robert Smith wrote:

> Any concern about the aero-digestive tract?
>
> Rob Smith
>
> On Sep 16, 2009, at 4:39 AM, Ross Hofmeyr wrote:
>
>> Hi Matthieu,
>>
>> In my setting (South Africa, state service, high incidence of violent
>> trauma) this really is 'bread and butter'.  Patient would almost
>> certainly
>> not have got the CT scan; may have had a FAST if there was someone
>> on duty
>> able to perform and an U/S machine was available (usually stolen
>> from the
>> gynae department...)
>>
>> Management would have been ABCD etc, followed by simple tube
>> thoracostomy.
>> With a benign abdominal examination the patient would get admitted
>> to the
>> ward for 'abdo obs' - serial abdominal examination, preferably by
>> the same
>> examiner and every four hours.  Development of haemodynamic
>> instability or
>> peritonitis would earn him an immediate "full colour real-time
>> stereotactic
>> CT" (aka laparotomy, *grin*).
>>
>> I know some of the academic hospitals have studies on the go where
>> this
>> class of patient is getting diagnostic thoracoscoopy/laparoscoy to
>> examine
>> the diaphragm, and are picking up more diaphragmatic injuries.  Tim
>> Hardcastle will hopefully comment on his (extensive) experience in
>> this type
>> injury.
>>
>> Serial abdominal examination remains one of the cheapest and best
>> ways to
>> assess the stable penetrating trauma patient with a quiet belly.
>>
>> Hope this is helpful,
>> Ross.
>>
>> 2009/9/15 Matthieu G. <mat.genz at gmail.com>
>>
>>> Dear list members,
>>>
>>> I would greatly appreciate your input on this case:
>>>
>>> 28 y.o. male, presents to the ER 24 hours after being stabbed twice
>>> to the
>>> thoracoabdominal area during a mass gathering. The patient is
>>> obviously
>>> intoxicated on psychoactive drug, complains of swelling and only
>>> very little
>>> pain. Vitals within normal limits. Clinical exam is remarkable for
>>> a massive
>>> cervical and left thoracic subcutaneous emphysema, 2 small stab
>>> wounds to
>>> the left latero-inferior chest wall and sub-xyphoid area.
>>> Hemodynamic is ok,
>>> positive Hamman sign, no dyspnea, abdomen is soft and non tender.
>>> Images of
>>> chest xray and chest CT scan are attached: subcutaneous emphysema,
>>> pneumomediastinum, small left PTX. Abdominal CT is negative, with no
>>> evidence of solid organ injury, no free air or fluid in peritoneal
>>> cavity.
>>>
>>> How would you manage this case? I know this kind of trauma is bread
>>> and
>>> butter in some countries, but penetrating trauma are rather
>>> infrequent in my
>>> practice. I am particularly worried about a possible left
>>> diaphragmatic
>>> injury.
>>>
>>> Matthieu Gensburger
>>>
>>> Matthieu Gensburger
>>> --
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>>>
>>
>>
>>
>> -- 
>> Dr Ross Hofmeyr
>> wildmedic at gmail.com
>> ross at wildmedix.com
>> www.wildmedix.com
>> Tel: +2784 54 99259
>> Skype:  wildmedic
>> “Semper Paratus”
>> --
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>
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Stab wound to the thoracoabdominal area