a 53-year - old man arrived at dankook university hospital trauma center with a steel bar impaling his torso .
he had fallen at a construction site , from a height of about 15 m. a steel bar entered his chest , passed through the epigastrium and exited posteriorly at the right scapula ( fig .
the diameter of the bar was about 2.5 cm , and the bar protruded from both sides ( 20 cm anteriorly and 30 cm posteriorly ) .
the patient was carefully transferred to a resuscitation bed and placed in a semi - reclining position to avoid further manipulation of the impaled object .
the patient had unstable vital signs on arrival showing a blood pressure of 87/49 mm hg with signs of hypoxemia ( pao2 55 mm hg , spo2 85% ) , a heart rate of 124 bpm , and a low hemoglobin level of 11.2 mg / dl .
closed thoracostomy was performed due to hemothorax , which was revealed by chest x - ray , and about 2,000 ml of fresh blood was drained ( fig .
systolic blood pressure was slightly elevated to 90 mm hg after transfusion ; however , a large amount of hemoptysis and bleeding from the external wound persisted .
the hemoglobin level decreased from 11.2 mg / dl to 6.5 mg / dl for 20 minutes despite the transfusion .
emergency operation for exploration and removal of the bar was planned in consultation with an experienced hepatobiliary surgeon . due to the penetrated bar
thus , prior to the operation the posterior segment of the steel bar just above the skin level was cut off with an electric saw .
, right side thoracoabdominal incision was made from the posterior chest to the middle line of the abdomen to cover the entire penetrated area .
after anatomic exposure , the steel bar was removed carefully in order to handle the bleeding promptly .
primary exploration was performed by both teams in sequence . in the pleural space , only the right lower lobe was completely penetrated , and bleeding from the hole in the posterior chest wall was observed . while the exploration for thoracic cavity , gauze packing and manual compression for bleeding control were performed . after acute damage control ,
a right lower lobectomy was performed because the bleeding from the lung was most notable and hemoptysis persisted .
two - lung ventilation was started following extraction of the right lower lobe ( fig .
2a ) , and bleeding from the pleural space and hemoptysis were controlled successfully . in the abdominal cavity , the lateral segment of the liver was penetrated , but no other organs were injured .
lateral sectionectomy of the liver was performed , which stabilized the patient s vital signs .
drains from both sides were located and the diaphragm was repaired using intermittent silk sutures .
the chest and abdomen were closed in a layer - by - layer manner , including the defect in the posterior chest wall .
the patient became stable without additional bleeding from the drains , and was extubated without sequelae on postoperative day 2 .
open reduction and screw fixation for the right distal femur fracture , which was acquired during the fall injury , was performed on postoperative day 13 .
the patient became stable enough to be transferred to a smaller institution for rehabilitation and was discharged on postoperative day 37 .
the patient is currently regularly followed up through the outpatient department and his present - day performance status is excellent .
. these injuries usually involve vital organs such as the heart , lung , or the great vessels .
fatal conditions such as hypoxemia , airway obstruction , hemorrhage , cardiac tamponade , and aspiration can lead to death within 30 minutes to 3 hours .
however , it is reported that patients with these conditions who are immediately transferred alive to a hospital have a high probability of survival . therefore , cautious extrication from the scene and rapid transportation to a trauma center are crucial factors for a survival outcome . compared to right thoracic injury
, left - side injury has higher mortality and morbidity because of the location of the heart and aorta .
one of the important principles of managing impaled patients is that the penetrating object should not be removed outside of the operating theater .
the piercing object in situ has a tamponade effect on the surrounding vasculature , which itself has a hemorrhage control effect .
bleeding from the external wound or hemoptysis can not be controlled if the foreign object is removed without preparation .
the patient on a bed without manipulation is also problematic . placing the patient in the supine position
a semi - reclining position is recommended for intubation and basic radiologic evaluation , and facilitated by placing several pillows beneath the patient s back .
a sitting position or lateral decubitus position are alternatives in this scenario . carefully severing the penetrating object immediately above the level of the skin
this can prevent unintentional dislodgement and facilitate positioning of the patient on the operating bed .
double - lumen tube intubation is the ideal option if lung parenchymal injury accompanying hemoptysis is suspected .
however , in practice , there are many restrictions such as inadequate position , lack of time for resuscitation , and poor hemodynamic status .
wide surgical exposure to cover the entire injured area should be performed , involving sternotomy , thoracotomy , laparotomy , or both . in this case , a large right thoracoabdominal incision was made for simultaneous hemorrhage control in both the thorax and abdomen , so that injured organs , chest wall , lung , diaphragm , and liver could be visualized . while left thoracoabdominal incisions are familiar to surgeons due to thoracoabdominal aortic operations , right thoracoabdominal exposure is performed considerably less frequently .
in addition , wide debridement is recommended by removing as much necrotic tissue as possible because the impaled object is likely to be severely contaminated . however , lung preservation is desirable to prevent empyema formation .
this type of injury is very rare and can be uncomfortable for physicians to treat . in many cases ,
the extent of injury is obscure , and there is limited time for evaluation and resuscitation due to poor vital signs . rapid and safe prehospital activity is crucial for survival .
additionally , the impaled object should not be removed before the patient reaches the operating theater
. the outcome of impalement injury can be improved by appropriate treatment by a multidisciplinary surgical team .
 a 53-year - old man arrived at the trauma center with a steel bar penetrating from the epigastrium to the right scapula . 
 he was hypotensive and hypoxic , and immediate resuscitation and basic evaluation were performed . 
 an emergency operation was performed due to an unstable hemodynamic state . 
 multiple injuries were confirmed in the right lower lobe , posterior chest wall , diaphragm , and liver lateral segment . 
 right lower lobectomy and liver lateral sectionectomy were performed following removal of the bar . 
 the patient recovered without additional hemorrhage after the surgery , and was transferred to a rehabilitation institution with periodic follow - up . 
Case report
Discussion