Abdominal Impalement from Motor Vehicle Crash

Abstract

A 21-year-old unrestrained male driver was impaled by a 2 15.2 cm wooden board that penetrated the car during a motor vehicle collision (Fig 1). Oral and intravenous contrast-enhanced computed tomogram (CT) showed the board overlying the expected location of the left common iliac artery and vein, which were not visualized as discrete contrast-containing structures (Fig 2). The right common iliac artery and vein were clearly identified. There was no evidence of extravasation. Surgical exploration following proximal arterial control demonstrated transection of the left common iliac vein, intimal injury of the left common iliac artery with thrombosis extending into the right common iliac artery, and large leftflank and right groin wounds. Significant venous bleeding occurred following removal of the board. Impalement injuries are an uncommon subset of penetrating injuries, in which an elongated object penetrates and remains imbedded in the patient. 1 Impalements usually occur in construction accidents or in motor vehicle crashes. 2 Fortunately impalement victims do not always sustain serious injuries to critical structures, as the impaling object frequently displaces organs rather than penetrating them. However, critical vascular injuries may be tamponaded by the impaling object. Recognition of these injuries before surgery is essential in identifying sites of potentially severe bleeding during removal of the object. The path of the impaling object is sometimes challenging to understand, especially when the impalement occurs in 1 position while hospital evaluation and imaging occurs in another (ie, a driver sitting in a car with flexed hips vs a supine patient). Such position differences may also make surgical extraction of the impaled object difficult. Once the spine has been cleared, flexion or extension of the patient may ease removal of the object, which is otherwise under tension in the supine patient. The impaled object should only be removed in the operating room, not in the field. In this case, the board both transected and tamponaded the left common iliac vein. Significant venous bleeding occurred after intraoperative removal of the board. Removal of the board in the field would likely have resulted in exsanguination. In thefield, external portions of the impaled object can be separated from the patient with appropriate tools, such as saws or acetylene torches. Transporting the patient with external stabilization of the impaling object will minimize its’ movement. These same principles should be considered when imaging the patient, and creative