Abdominal Impalement from Motor Vehicle Crash

Abdominal Impalement from Motor Vehicle Crash

Abdominal Impalement from Motor Vehicle Crash Joel A. Gross, MD,a Eileen M. Bulger, MD,b Amorita Guno, MD,a and Hugh Foy, MDb A 21-year-old unrestrai...

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Abdominal Impalement from Motor Vehicle Crash Joel A. Gross, MD,a Eileen M. Bulger, MD,b Amorita Guno, MD,a and Hugh Foy, MDb

A 21-year-old unrestrained male driver was impaled by a 2 ⫻ 15.2 cm wooden board that penetrated the car during a motor vehicle collision (Fig 1). Oral and intravenous contrast-enhanced computed tomogram (CT) showed the board overlying the expected location of the left common iliac artery and vein, which were not visualized as discrete contrast-containing structures (Fig 2). The right common iliac artery and vein were clearly identified. There was no evidence of extravasation. Surgical exploration following proximal arterial control demonstrated transection of the left common iliac vein, intimal injury of the left common iliac artery with thrombosis extending into the right common iliac artery, and large left flank and right groin wounds. Significant venous bleeding occurred following removal of the board. Impalement injuries are an uncommon subset of penetrating injuries, in which an elongated object penetrates and remains imbedded in the patient.1 Impalements usually occur in construction accidents or in motor vehicle crashes.2 Fortunately impalement victims do not always sustain serious injuries to critical structures, as the impaling object frequently displaces organs rather than penetrating them. However, critical vascular injuries may be tamponaded by the impaling object. Recognition of these injuries before surgery is essential in identifying sites of potentially severe bleeding during removal of the object. The path of the impaling object From the aDepartment of Radiology, Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA; and bDepartment of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA. Reprint requests: Joel A. Gross, MD, University of Washington School of Medicine, Department of Radiology, Harborview Medical Center, 325 Ninth Avenue, Box 359728, Seattle, WA 98104-2499. E-mail: jagross@ uw.edu. Curr Probl Diagn Radiol 2012;41:142-143. © 2012 Mosby, Inc. All rights reserved. 0363-0188/$36.00 ⫹ 0 doi:10.1067/j.cpradiol.2011.07.014

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FIG 1. 21-year-old male with impalement injury. Photograph shows board entering left flank and exiting right groin.

is sometimes challenging to understand, especially when the impalement occurs in 1 position while hospital evaluation and imaging occurs in another (ie, a driver sitting in a car with flexed hips vs a supine patient). Such position differences may also make surgical extraction of the impaled object difficult. Once the spine has been cleared, flexion or extension of the patient may ease removal of the object, which is otherwise under tension in the supine patient. The impaled object should only be removed in the operating room, not in the field. In this case, the board both transected and tamponaded the left common iliac vein. Significant venous bleeding occurred after intraoperative removal of the board. Removal of the board in the field would likely have resulted in exsanguination. In the field, external portions of the impaled object can be separated from the patient with appropriate tools, such as saws or acetylene torches. Transporting the patient with external stabilization of the impaling object will minimize its’ movement. These same principles should be considered when imaging the patient, and creative

Curr Probl Diagn Radiol, July/August 2012

FIG 2. Contrast-enhanced CT. (A) Wide windows3,4 show grain of penetrating board, useful for distinguishing smaller wooden objects from gas. Extensive soft-tissue disruption in right groin is shown. (B) Arterial phase abdominal image shows nonobstructing thrombus in right common iliac artery (arrow), without visualization of left common iliac artery. (C) Portal venous phase abdominal image shows contrast in right common iliac artery (short arrow) and vein (long arrow), but nonvisualization of left common iliac artery and vein (medial to board).

improvisation may be necessary. For example, additional portions of the external object may need to be removed before the patient can fit into the CT scanner. The patient may also require additional support during imaging so the impaling object remains immobile and does not cause further injury. Although impalement injuries are uncommon, critical evaluation of anatomic structures along the path of the impaled object is essential to understand the extent of injury and avoid life-threatening complications, such as hemorrhage following its removal. Imaging should be performed minimizing movement of the impaled object.

Curr Probl Diagn Radiol, July/August 2012

REFERENCES 1. Eachempati SR, Barie PS, Reed RL II. Survival after transabdominal impalement from a construction injury: A review of the management of impalement injuries. J Trauma 1999;47:864-6. 2. Thomson BN, Knight SR. Bilateral thoracoabdominal impalement: Avoiding pitfalls in the management of impalement injuries. J Trauma 2000;49:1135-7. 3. Dalley RW. Intraorbital wood foreign bodies on CT: Use of wide bone window settings to distinguish wood from air. AJR 1995;164:434-5. 4. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: Imaging appearance. AJR 2002;178:557-62.

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