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Doorway Diagnosis

The Diagnosis: Impalement Injury

Greenberg, Michael I. MD, MPH

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doi: 10.1097/01.EEM.0000292316.07611.3b

    This patient has suffered what is known as an impalement injury. A wooden post has gone through the entire width of his thigh. While it may be categorized as a “puncture wound,” it is certainly the most serious variety of puncture wound that could be imagined! Impalements generally involve large forces generated by the patient's entire body weight falling on an object.

    Impalement injuries are relatively rare. The most common anatomical site of involvement is the extremities. Although thoracic impalements do occur, only a few of such injuries limited to the thorax have been reported in the literature. The degree of damage in any case varies according to the involved organs, with impalement of the heart or great vessels having an extremely high mortality.

    The following specific principles in the emergent management of such cases should be borne in mind. First, no attempt should be made at the scene (or in the ED) to remove the impaled object. Instead, at the scene, the object should be carefully reduced to a manageable size and stabilized in place to facilitate transportation. All usual trauma management protocols should be followed, including airway control and fluid resuscitation as needed.

    Many authorities acknowledge the need to proceed to the operating room with patients in unstable condition. However, a more deliberate approach to impalement injuries may be called for, including emergent imaging to determine the exact nature and extent of injury in hemodynamically stable patients. Involvement of appropriate surgical specialists quite promptly after the patient's arrival is essential. The impaled object should be extracted in the operating room under direct vision to prevent uncontrolled hemorrhage and damage to important structures. In the operating room, necrotic tissues should be removed and wounds widely debrided to help prevent infection. The administration of antibiotics started in the ED as well as tetanus immunization is standard.

    One important challenge for the emergency physician is that in some cases of impalement, endotracheal intubation may be needed with the patient placed in unusual and awkward body positions to accommodate the protruding impaled object.

    Figure. C
    Figure. C:
    ourtesy of L. Kaplan, MD
    © 2001 Lippincott Williams & Wilkins, Inc.