A 37 year old man was found collapsed at the roadside and taken to the emergency department. Communication was difficult, as the patient could not speak English. There was a wound in the left second intercostal space on the midclavicular line, which was bleeding and was bubbling air. A drain was inserted, bleeding controlled, and his wounds sutured. Chest x ray later confirmed satisfactory placement of the drain. The following day, swelling and discharge indicated oesophageal damage, which was later confirmed by gastrografin swallow. With conservative management in hospital for 2 weeks, he made a full recovery and was discharged.
- CXR, chest x ray
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A 37 year old man was found collapsed at the roadside and taken to the emergency department by ambulance at 0200. He had sustained a stab wound to the left anterior chest and an injury to the left side of the head. Further history was unobtainable, as the patient could not speak or understand English.
The patient was alert, with no airway compromise and adequate breathing. There was no evidence of neck injury but, in view of his head injury and communication difficulty, his neck was immobilised. Pulse was 110 beats/min, blood pressure 130/70 mm Hg, respiratory rate 24 breaths/min, oxygen saturation 96% on room air and capillary glucose 7 mmol/l.
The patient had a 30 mm laceration behind the left ear. More importantly, there was a laceration measuring 20 mm×10 mm in the left second intercostal space on the midclavicular line, which was bleeding and was bubbling air. Bleeding was controlled with digital pressure, and a drain was rapidly inserted into the fiftth intercostal space, without a preliminary chest x ray (CXR). His lacerations were sutured. CXR later confirmed satisfactory placement of the drain, with inflated lungs, and the patient was admitted to the emergency observation ward.
Next morning, a translator was employed to assist with communication. The patient was stable and feeling well. The chest drain was oscillating, with expanded lungs, and his wounds appeared satisfactory. He was served food in the afternoon. One hour later, he complained of left chest discomfort. He had developed a small swelling in the left upper chest and lower neck region. There was a porridge-like discharge from the chest wound, which appeared like anchovy sauce, with a layer of stringy clear fluid, suggestive of saliva. There was also some air leakage (fig 1). CXR revealed surgical emphysema in the left chest wall and the neck. A provisional diagnosis of oesophageal injury was made. An urgent gastrografin swallow showed leakage from the lower cervical oesophagus tracking laterally through the soft tissues anterior to the left lung apex (fig 2).
The consultant in emergency medicine reviewed the patient, along with an oesophageal surgeon, who opted for conservative management. The patient was placed on total parenteral nutrition. A computed tomography scan next day confirmed leakage from the oesophagus, just above the level of the thoracic inlet, with a haematoma in the mediastinum and small bilateral pleural effusion. Subsequent angiogram was normal.
The patient’s chest wound discharged for 2 weeks, but his stay in hospital remained uneventful. He was discharged home on day 18, following a gastrografin swallow that confirmed no further leakage.
Penetrating injuries to the chest and neck following assault with knives or bullets are relatively common. The second intercostal space has been considered safe for chest decompression and occasional insertion of chest drainage. However, its proximity to zone I of the neck and the vital structures in the thoracic outlet make it a special case. In our patient, the injury was due to a long knife, which traversed the chest superficial to the rib cage and above the clavicle, causing a zone I injury to the neck.
During the 1960s and 1970s, the golden rule for penetrating injuries to the neck was for mandatory surgical exploration. This management protocol emerged from military experience during wartime.1,2 The policy was based on the complex anatomy of the neck, the relative risks involved, and the favourable results obtained with this approach.3 In civil settings, with rates of negative neck explorations up to 75%,4 critical retrospective studies in the mid-1970s and 1980s supported a more selective approach to asymptomatic patients. As the structures in zone 1 are difficult to assess clinically, most studies advocate mandatory arteriogram and gastrografin swallow.5 Over the past decade there has been a shift from a policy of mandatory exploration of the neck towards selective non-operative management.6,7
The published literature supports insertion of a chest drain in clinically unstable patient with an obvious penetrating chest trauma. This patient sustained an unusual penetrating oesophageal injury in zone I secondary to a transthoracic extrapleural stab wound. He remained haemodynamically stable.
Is it reasonable practice to insert a chest drain without a preliminary CXR in obvious penetrating chest trauma, with a bubbling wound but a clinically stable patient? It remains the practice of the local emergency department to do so.
Competing interests: none declared
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