Submitted By
Dr. Edoardo Ghirardi,
Chemist, Emergency Service 118, Italian Red Cross team leader
Case presentation
Last Sunday afternoon, March, 2nd, a 69 y.o. man was attending to his garden works, using a ladder for trimming plants over the top of the fence. Probably due to a bad foot position on the step of the ladder He fell down directly on one of the “darts” positioned on the top of the fence. In this way He got his thorax impaled with one dart.
On scene
We were called out for an accidental fall on a fence from the first floor of a house. Our way to the target got only two minutes because the scene was not so far from our Operative Central. We found the patient suspended by the dart and standing in erect position sustained by a passerby who used his ladder to climb the wall. We first saw the dart was impaled in the posterior-axillar right line upwards for about 15 cm and the blood loss was of about 500 mL. The hemorrhage was quite stopped. We noticed that the plastic litter box which had been placed under the feet of the patient was getting more and deformed and We decided to support Him by his legs and pelvis. We had to wait few minutes for the intervention of the Firefighters and the Emergency Doctor.
The patient was conscious and so remained for all the time and collaborating with rescue team telling the accident. With the arrival of the Firefighters We asked them to cut the dart which had the base diameter of about 2 cm. We asked to use a pneumatic cutter and not a rotating blade to prevent any burning, vibration or excessive contamination of the injury. Once the dart has been separated from the fence We sustained the patient with our hands and delicately laid Him on a backboard and down on the stretcher. Keeping the immobilization We rotated him on the left lateral position. Once visited his vital parameters were SpO2 98%, HR 80 bpm, BP 150/70 mmHg and GCS 15. Laying on the backboard it was possible to remove the foreign matter which revealed to be about 20cm long.
Normal heart and lung sounds were confirmed by the Emergency Doctor who excluded important pneumothorax, venous hemorrage or neurologic compromission. No paresthesia has been found nor nervous plexa damage. The ECG was normal. We positioned a G18 venous catheter and administered 500mL of colloids “Emagel” (poligelin). We put a temporary sterile dressing on the wound. The patient declared to suffer from a non specified heart disease and to have been operated many years ago, revealing the scar of a sternotomy. Arrived at the hospital the emergency dept. doctor made an accurate evaluation of the wound, temporarily applied a sterile dress and started the necessary analyses thanks to the stable conditions of the man.
X-Rays revealed a left calcific pachipleuritis. The costophrenic recess was obliterated and the mediastinum little shifted from right. No pleuroparenchymal hotbed lesions in act. Results of median sternotomy due to a previous cardiac operation. Subcutaneous emphysema along the right thoracic wall.
At the blood’s examinations the patient had hemoglobin: 13.5 g/dL, hematocrit: 39.3%, platelets 310x103, aPTT: 27,3s, aPTT ratio: 0.96, creatine kinase: 678 U/L.
A subcutaneous drain was placed at the basis of the right chest. The wound has been washed and sutured leaving the drain. Antibiotic therapy with ceftriaxone 1g IM has been started. Antitetanus prophylaxis has been practiced. The patient has been hospitalized for some days for the observation of the clinical evolution.
Discussion
The patient has been found in a really particular condition, suspended and hardly immobilizable. On our ambulance we have only these immobilization devices: backboard, cervical collars, vacuum mattress, Kendrick immob. device, splints and the stretcher. As We found none suitable for the patient when He was still suspended, We preferred manual immobilization. We moved Him very slowly and gently laid on the backboard, on his left side. We decided to remove the dart because there was no more bleeding and the permanence of the object could cause further damages. Removing it has been possible because We saw the tail of the dart could come out without damaging anything else.
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