Unusual presentation of chest penetrating injury by metallic bar Dr. Raed Mostafa Alareeni EBTS , TBTS , PBTS , Member of Egyptian , European , Turkish , American thoracic society

Introduction Thoracic penetrating injuries present a frequent and challenging problem. The majority of these injuries can be treated successfully with simple procedure. However some cases present a life- threatening condition and require an aggressive intervention The selection of the patients for operation or observation can be made by clinical examination and appropriate investigations. Penetrating chest trauma is frequently caused by gunshot and non—gunshot-related incidents such as stabs, traffic accidents and impalements.

Introduction Rare penetrating chest injury by kebab's skewer,hockey stick, or self-inflicted with 5 knives has been reported. We present here a rare case of a 22-year-old man who sustained penetrating chest injury caused by a metallic (iron) bar.

Case report A 22-year-old male tuk-tuk driver presented to the emergency room of Al- shifa Hospital after he have been penetrated by a metallic (iron) bar projecting from the front trolley after a sudden stoppage while he was driving his tuk-tuk.

Case report In the emergency room, the patient was conscious, oriented, and stable hemodynamically. Clinical examination showed metallic (iron) rod with entry site at the left upper anterior region and exit site at the left scapular region, with no other external injury, equal bilateral air entry, audible heart sound and no added sound, no raised JVP, flat and soft abdomen with, palpable peripheral pulses, and with all limbs moving. The patient's oxygen saturation was maintained by a 5- liter oxygen face mask, and he was resuscitated with intravenous fluid through one large bore cannula.

Case report The patient was transferred to the operating room, left posterolateral thoracotomy was performed, the metallic bar had crossed the chest cavity surprisingly just above the apex of the left lung and arch of aorta, no esophageal injury and no injury of the lung or the major vessels except intercostal vessels in both the inlet and the outlet. the metallic rod was pulled out and hemostasis was done.

Case report Surgical wounds were closed with layers, and inlet and exit left open for secondary intention suture after a proper debridement . Bilateral chest tubes were inserted.

Case report The patient then was shifted to intensive care unit (ICU), the patient was treated by broad-spectrum antibiotics and weaned from mechanical ventilation. He was then discharged from ICU in the second day and admitted to the ordinary ward, after which he had uneventful recovery and was discharged from the hospital in good general condition

Discussion Thoracic trauma accounts for 25 % of all severe injuries. When associated with other injuries it rise the mortality rate up to 50 % as a result of hypovolemia and hypoxia. Although penetrating injuries of the thoracic are common, presentation with a large metallic bar penetration is rare . Various types of objects causing such injuries include glass, knife, barbed wire, plank, broomstick and metal hooks. Resuscitation and close monitoring prior to and during surgery, especially at the time of removal of the penetrating object, is vital with anticipation of major vascular injuries. Patient after 1 year

Discussion MOH paramedics contributed positively in managing this patient for several reasons. Firstly, they have reached the accident area on time, in which the patient has been transferred to hospital without delay. Secondly, paramedic were cautious while they were cutting the metallic rod, so that they don’t move the bar avoiding possible a serious injury. Patient after 1 year

Discussion In such situations, with this type of injury, a team of a general surgeon, a vascular or cardiac surgeon, should be presnt to remove the object and treat any potential complications. We suggest that in these impalement injuries, removal of iron bars should be under direct vision. Patient after 1 year

Dr. Raed Mostafa Alareeni Thank’s Dr. Raed Mostafa Alareeni