Introduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury.&nbsp;Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy.&nbsp;At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications.&nbsp;Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy

Farshidmehr, Pezhman

Hajebi, Reza

Rahimpour, Ehsan

Vezvaei, Payam

Zabihi, Hossein

English

Frontiers in Emergency Medicine (E-Journal)

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al     1 Copyright © 2020 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).  Case Study DOI: 10.22114/ajem.v0i0.185 Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study  Hossein Zabihi1,2, Pezhman Farshidmehr1, Reza Hajebi1, Ehsan Rahimpour1, Payam Vezvaei1,2*  1. Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.  2. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.  *Corresponding author: Payam Vezvaei; Email: payam.vezvaei@gmail.com  Published online: 2019-07-01 Abstract  Introduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications.  Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy. Key words: Case Management; Implements in-situ; Thoracic Injuries; Thoracoscopy; Wounds, Penetrating Cite this article as: Zabihi H, Farshidmehr P, Hajebi R, Rahimpour E, Vezvaei P. Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study. Adv J Emerg Med. 2020;4(1):e11. INTRODUCTIONDorsal penetrating thoracic injuries are commonly caused by sharp objects or bullets (1). The mortality rate of thoracic traumas is reported to be between 3.6% and 37% (2). They may be asymptomatic or in some cases, severely life threatening. They are usually complicated and require surgical treatment to save the patients (3).  Various strategies could be considered dealing with such cases. Thoracoscopy is much less  invasive than routine thoracotomy approach for managing patients with penetrating thoracic injuries in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury.  CASE PRESENTATION The patient was a 35-year-old man with a penetrating dorsolateral thoracic injury. The patient was injured by a knife through a street quarrel and brought to the emergency department (ED) by ambulance. The knife had entered the thoracic cavity from lateral to the left mid-clavicle line posteriorly at the level of the third intercostal space with about 4 cm of the blade inside the body (Figure 1).  Hematoma was detected at the site of the injury. Despite an elevated pulse rate (110 bpm), the patient was stable with the arterial blood pressure of 110/70 mmHg, respiratory rate of 18 and oxygen saturation of 96% in room air. We evaluated the patient by extended focused assessment with sonography in trauma (e-FAST)  Figure 1: The image of the patient at the time of ED entry  ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al     2 Copyright © 2020 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).  protocol which revealed possible pneumothorax, but no sign of hemothorax was observed. There was no abdominal free fluid and we did not detect any sign of pericardial effusion. The knife at the injury site did not allow performing anterior-posterior Chest X-Ray (CXR), therefore, a hemi-lateral CXR was taken to evaluate the extension of the injury. The radiograph was taken using a portable X-ray machine (Figure 2).  Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. We intended to have a better vision of the injury and remove the knife with thoracoscopy, and avoid wide thoracotomy, which is the routine treatment for patients with penetrating thoracic injuries.  At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space (Figure 3). There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. After removing the knife, we observed the site of the injury directly via the thoracoscope for 15 minutes to detect any sign of bleeding or complication. Because the patient was stable and no complications were detected, we removed the thoracoscope. We placed a chest tube at the same place the thoracoscope entered the thoracic cavity to avoid an extra scar. About 300 cc of blood was drained through the chest tube. We closed the site of the injury with 0-USP Braided – non absorbable SILK. We also performed an echocardiography to make sure that there was no sign of pericardial effusion. The patient was taken to the ICU. After one day, the chest tube did not drain any further fluid, the patient was stable and examinations were completely normal. Therefore, we decided to transfer the patient to the general ward where he was discharged after 5 days without any complications. DISCUSSIONS The unusual appearance of penetrating thoracic injuries, specially retained knife, may distract the medical team and focus their attention on the retained knife rather than the initial resuscitation and patient’s stability (4). A complete systematic examination is necessary, followed by assessing the depth of the injury and searching for possible vascular and neuromuscular injuries. Patients with vascular injuries may have normal arterial blood pressure and pulse rate since the blade can prevent hemorrhage by acting as a tamponade (4, 5).  The retained knife should be extracted cautiously because it may cause severe hemorrhage, hemodynamic deterioration and death (5). Thoracotomy is usually necessary in patients with penetrating thoracic injury especially in patients with the sharp object retained at the injury site. Thoracotomy allows surgeons to evaluate great vessel injuries and the extension of the penetration, and to remove the sharp object without any further damage (4). However, thoracotomy is an extremely invasive procedure which may result in infection, thromboembolism, lung injury, chronic post-thoracotomy pain, intercostal nerve injury,  etc. (6-8). Alternative approaches wherever possible will reduce these complications and result in better patient care and decreased costs.  Figure 2: The patient’s X-ray taken by portable X-ray machine   Figure 3: Inside view of the thoracic cavity during thoracoscopy ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al     3 Copyright © 2020 Tehran University of Medical Sciences  This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).  CONCLUSIONS Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy. ACKNOWLEDGMENTS None. AUTHORS’ CONTRIBUTION The author passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. CONFLICTS OF INTEREST None declared. FUNDING None declared. REFERENCES1. Battistella F, Benfield JR. Blunt and penetrating injuries of the chest wall, pleura and lungs. General thoracic surgery 5th ed Philadelphia: Lippincott Williams & Wilkins. 2000:815-31. 2. Ali J, Gana TJ, Howard M. Trauma mannequin assessment of management skills of surgical residents after advanced trauma life support training. J Surg Res. 2000;93(1):197-200. 3. Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, et al. Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005;201(3):343-8. 4. Thomson BN, Knight SR. Bilateral thoracoabdominal impalement: avoiding pitfalls in the management of impalement injuries. J Trauma. 2000;49(6):1135-7. 5. Sobnach S, Nicol A, Nathire H, Kahn D, Navsaria P. Management of the retained knife blade. World J Surg. 2010;34(7):1648-52. 6. Ziomek S, Read RC, Tobler HG, Harrell JE, Gocio JC, Fink LM, et al. Thromboembolism in patients undergoing thoracotomy. Ann Thorac Surg. 1993;56(2):223-7. 7. Rogers ML, Duffy JP. Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg. 2000;18(6):711-6. 8. Rogers M, Henderson L, Mahajan R, Duffy J. Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg. 2002;21(2):298-301.  

Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study

Advanced Journal of Emergency medicine

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al 
   
 1 Copyright © 2020 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
Case Study DOI: 10.22114/ajem.v0i0.185 
Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case 
Study 
 
Hossein Zabihi1,2, Pezhman Farshidmehr1, Reza Hajebi1, Ehsan Rahimpour1, Payam Vezvaei1,2* 
 
1. Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.  
2. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. 
 
*Corresponding author: Payam Vezvaei; Email: payam.vezvaei@gmail.com  
Published online: 2019-07-01 
Abstract  
Introduction: Various strategies could be considered dealing with penetrating thoracic injuries. 
Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which 
the sharp object remains in the body. The case presented in this article was managed with thoracoscopy 
for a penetrating dorsolateral thoracic injury. 
Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the 
emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 
saturation. Considering the patient's stability and the results of imaging which did not show any massive 
vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 
cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild 
laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence 
of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the 
thoracoscope without any complications.  
Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an 
appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and 
have appropriate conditions for thoracoscopy. 
Key words: Case Management; Implements in-situ; Thoracic Injuries; Thoracoscopy; Wounds, Penetrating 
Cite this article as: Zabihi H, Farshidmehr P, Hajebi R, Rahimpour E, Vezvaei P. Management of a Penetrating Thoracic Injury with 
Thoracoscopy; A Case Study. Adv J Emerg Med. 2020;4(1):e11. 
INTRODUCTION
Dorsal penetrating thoracic injuries are commonly 
caused by sharp objects or bullets (1). The 
mortality rate of thoracic traumas is reported to 
be between 3.6% and 37% (2). They may be 
asymptomatic or in some cases, severely life 
threatening. They are usually complicated and 
require surgical treatment to save the patients (3).  
Various strategies could be considered dealing 
with such cases. Thoracoscopy is much less  
invasive than routine thoracotomy approach for 
managing patients with penetrating thoracic 
injuries in which the sharp object remains in the 
body. The case presented in this article was 
managed with thoracoscopy for a penetrating 
dorsolateral thoracic injury.  
CASE PRESENTATION 
The patient was a 35-year-old man with a 
penetrating dorsolateral thoracic injury. The 
patient was injured by a knife through a street 
quarrel and brought to the emergency department 
(ED) by ambulance. The knife had entered the 
thoracic cavity from lateral to the left mid-clavicle 
line posteriorly at the level of the third intercostal 
space with about 4 cm of the blade inside the body 
(Figure 1).  Hematoma was detected at the site of 
the injury. Despite an elevated pulse rate (110 
bpm), the patient was stable with the arterial 
blood pressure of 110/70 mmHg, respiratory rate 
of 18 and oxygen saturation of 96% in room air. 
We evaluated the patient by extended focused 
assessment with sonography in trauma (e-FAST) 
 
Figure 1: The image of the patient at the time of ED entry 
 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al 
   
 2 Copyright © 2020 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
protocol which revealed possible pneumothorax, 
but no sign of hemothorax was observed. There 
was no abdominal free fluid and we did not detect 
any sign of pericardial effusion. The knife at the 
injury site did not allow performing anterior-
posterior Chest X-Ray (CXR), therefore, a hemi-
lateral CXR was taken to evaluate the extension of 
the injury. The radiograph was taken using a 
portable X-ray machine (Figure 2).  
Considering the patient's stability and the results 
of imaging which did not show any massive 
vascular injury, the patient was taken to the 
operation room for thoracoscopy. We intended to 
have a better vision of the injury and remove the 
knife with thoracoscopy, and avoid wide 
thoracotomy, which is the routine treatment for 
patients with penetrating thoracic injuries.  
At thoracoscopy, we saw 4 cm of the blade in the 
thoracic cavity between the third and fourth 
intercostal space (Figure 3). There was a mild 
laceration of lung tissue without any active 
bleeding. Considering the position of the blade and 
the absence of active bleeding and vascular injury 
at the trauma site, we successfully removed the 
blade by the thoracoscope without any 
complications. After removing the knife, we 
observed the site of the injury directly via the 
thoracoscope for 15 minutes to detect any sign of 
bleeding or complication. Because the patient was 
stable and no complications were detected, we 
removed the thoracoscope. We placed a chest tube 
at the same place the thoracoscope entered the 
thoracic cavity to avoid an extra scar. About 300 cc 
of blood was drained through the chest tube. We 
closed the site of the injury with 0-USP Braided – 
non absorbable SILK. We also performed an 
echocardiography to make sure that there was no 
sign of pericardial effusion. 
The patient was taken to the ICU. After one day, 
the chest tube did not drain any further fluid, the 
patient was stable and examinations were 
completely normal. Therefore, we decided to 
transfer the patient to the general ward where he 
was discharged after 5 days without any 
complications. 
DISCUSSIONS 
The unusual appearance of penetrating thoracic 
injuries, specially retained knife, may distract the 
medical team and focus their attention on the 
retained knife rather than the initial resuscitation 
and patient’s stability (4). A complete systematic 
examination is necessary, followed by assessing 
the depth of the injury and searching for possible 
vascular and neuromuscular injuries. Patients 
with vascular injuries may have normal arterial 
blood pressure and pulse rate since the blade can 
prevent hemorrhage by acting as a tamponade (4, 
5).  
The retained knife should be extracted cautiously 
because it may cause severe hemorrhage, 
hemodynamic deterioration and death (5). 
Thoracotomy is usually necessary in patients with 
penetrating thoracic injury especially in patients 
with the sharp object retained at the injury site. 
Thoracotomy allows surgeons to evaluate great 
vessel injuries and the extension of the 
penetration, and to remove the sharp object 
without any further damage (4). However, 
thoracotomy is an extremely invasive procedure 
which may result in infection, thromboembolism, 
lung injury, chronic post-thoracotomy pain, 
intercostal nerve injury,  etc. (6-8). Alternative 
approaches wherever possible will reduce these 
complications and result in better patient care and 
decreased costs. 
 
Figure 2: The patient’s X-ray taken by portable X-ray 
machine 
 
 
Figure 3: Inside view of the thoracic cavity during 
thoracoscopy 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(1):e11 Zabihi et al 
   
 3 Copyright © 2020 Tehran University of Medical Sciences  
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
CONCLUSIONS 
Our experience of removing a retained knife by 
thoracoscopy showed that it can be an 
appropriate alternative for patients with 
penetrating thoracic injury who are 
hemodynamically stable and have appropriate 
conditions for thoracoscopy. 
ACKNOWLEDGMENTS 
None. 
AUTHORS’ CONTRIBUTION 
The author passed four criteria for authorship 
contribution based on recommendations of the 
International Committee of Medical Journal 
Editors. 
CONFLICTS OF INTEREST 
None declared. 
FUNDING 
None declared. 
REFERENCES
1. Battistella F, Benfield JR. Blunt and penetrating injuries of the chest wall, pleura and lungs. General 
thoracic surgery 5th ed Philadelphia: Lippincott Williams & Wilkins. 2000:815-31. 
2. Ali J, Gana TJ, Howard M. Trauma mannequin assessment of management skills of surgical residents 
after advanced trauma life support training. J Surg Res. 2000;93(1):197-200. 
3. Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, et al. Trauma deaths in a mature 
urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005;201(3):343-8. 
4. Thomson BN, Knight SR. Bilateral thoracoabdominal impalement: avoiding pitfalls in the management 
of impalement injuries. J Trauma. 2000;49(6):1135-7. 
5. Sobnach S, Nicol A, Nathire H, Kahn D, Navsaria P. Management of the retained knife blade. World J 
Surg. 2010;34(7):1648-52. 
6. Ziomek S, Read RC, Tobler HG, Harrell JE, Gocio JC, Fink LM, et al. Thromboembolism in patients 
undergoing thoracotomy. Ann Thorac Surg. 1993;56(2):223-7. 
7. Rogers ML, Duffy JP. Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg. 
2000;18(6):711-6. 
8. Rogers M, Henderson L, Mahajan R, Duffy J. Preliminary findings in the neurophysiological assessment 
of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg. 2002;21(2):298-301. 
 


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Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study

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