Thoracic Stab Wound With Impaled Knife

Abstract

A 52 year old man was brought to the Bellevue Trauma Center after a single stab wound to the upper back. The patient arrived hemodynamically normal with a Glasgow Coma Scale score of 15. He denied any chest pain or shortness of breath. Physical examination revealed mildly decreased breath sounds on the left and a sharp kitchen knife impaled in his upper back (Fig. 1). Pulse exams were equal in both upper extremities. Secondary survey was otherwise normal. FAST examination revealed no pericardial effusion or free intraperitoneal fluid. A chest radiograph revealed the foreign object as well as an asymmetric lucency at the left costophrenic angle consistent with a small pneumothorax (Fig. 2). A left-sided thoracostomy tube was placed with air and minimal blood return. Given his hemodynamic stability, the patient was brought for a CT scan of the chest with IV contrast to better delineate the knife blade tract (Fig. 3). The computed tomography (CT) demonstrated the knife blade entering the left lower lobe and terminating 8 mm from the descending thoracic aorta with no evidence for aortic or esophageal injury. The knife was withdrawn under controlled conditions in the operating room with the patient prepped and draped. His vital signs remained normal after a period of observation. The chest tube was removed after 2 days. The patient was subsequently discharged and doing well on follow-up. Evaluation of patients with impaled foreign bodies has evolved with the expansion and accessibility of diagnostic modalities such as CT scanning. The anatomic information acquired by CT, in conjunction with reliable and repeated clinical examination, allows for non-operative management of injuries that once mandated a more aggressive surgical approach.