Puncture Wound
   HOME

TheInfoList



OR:

Penetrating trauma is an open wound
injury Injury is physiological damage to the living tissue of any organism, whether in humans, in other animals, or in plants. Injuries can be caused in many ways, including mechanically with penetration by sharp objects such as teeth or with ...
that occurs when an object pierces the
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...
and enters a tissue of the body, creating a deep but relatively narrow entry
wound A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...
. In contrast, a blunt or ''non-penetrating'' trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area. A penetrating injury in which an object enters the body or a structure and passes all the way through an exit wound is called a perforating trauma, while the term ''penetrating trauma'' implies that the object does not perforate wholly through. In gunshot wounds, perforating trauma is associated with an entrance wound and an often larger exit wound. Penetrating trauma can be caused by a foreign object or by fragments of a broken bone. Usually occurring in
violent crime A violent crime, violent felony, crime of violence or crime of a violent nature is a crime in which an offender or perpetrator uses or threatens to use harmful Force (law), force upon a victim. This entails both crimes in which the violence, vio ...
or armed combat, penetrating injuries are commonly caused by gunshots and
stabbing A stabbing is penetrating trauma, penetration or rough contact with a sharp or pointed object at close range. ''Stab'' connotes purposeful action, as by an Assassination, assassin or murderer, but it is also possible to accidentally stab oneself ...
s. Penetrating trauma can be serious because it can damage internal organs and presents a risk of shock and
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
. The severity of the injury varies widely depending on the body parts involved, the characteristics of the penetrating object, and the amount of
energy Energy () is the physical quantity, quantitative physical property, property that is transferred to a physical body, body or to a physical system, recognizable in the performance of Work (thermodynamics), work and in the form of heat and l ...
transmitted to the tissues. Assessment may involve
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
s or
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
s, and treatment may involve surgery, for example to repair damaged structures or to remove foreign objects. Following penetrating trauma, spinal motion restriction is associated with worse outcomes and therefore it should not be done routinely.


Mechanism

As a missile passes through tissue, it decelerates, dissipating and transferring
kinetic energy In physics, the kinetic energy of an object is the form of energy that it possesses due to its motion. In classical mechanics, the kinetic energy of a non-rotating object of mass ''m'' traveling at a speed ''v'' is \fracmv^2.Resnick, Rober ...
to the tissues. The
velocity Velocity is a measurement of speed in a certain direction of motion. It is a fundamental concept in kinematics, the branch of classical mechanics that describes the motion of physical objects. Velocity is a vector (geometry), vector Physical q ...
of the projectile is a more important factor than its mass in determining how much damage is done; kinetic energy increases with the square of the velocity. In addition to injury caused directly by the object that enters the body, penetrating injuries may be associated with secondary injuries, due for example to a blast injury. The path of a projectile can be estimated by imagining a line from the entrance wound to the exit wound, but the actual trajectory may vary due to ricochet or differences in tissue density. In a cut, the discolouration and the swelling of the skin from a blow happens because of the ruptured blood vessels and escape of blood and fluid and other injuries that interrupt the circulation.


Cavitation


Permanent

Low-velocity items, such as knives and swords, are usually propelled by a person's hand, and usually do damage only to the area that is directly contacted by the object. The space left by tissue that is destroyed by the penetrating object as it passes through forms a cavity; this is called permanent cavitation.


Temporary

High-velocity objects are usually
projectile A projectile is an object that is propelled by the application of an external force and then moves freely under the influence of gravity and air resistance. Although any objects in motion through space are projectiles, they are commonly found ...
s such as
bullet A bullet is a kinetic projectile, a component of firearm ammunition that is shot from a gun barrel. They are made of a variety of materials, such as copper, lead, steel, polymer, rubber and even wax; and are made in various shapes and constru ...
s from high-powered rifles, such as
assault rifle An assault rifle is a select fire rifle that uses an intermediate cartridge, intermediate-rifle cartridge and a Magazine (firearms), detachable magazine.C. Taylor, ''The Fighting Rifle: A Complete Study of the Rifle in Combat'', F.A. Moyer '' ...
sDaniel Limmer and Michael F. O'Keefe. 2005. ''Emergency Care'' 10th ed. Edward T. Dickinson, Ed. Pearson, Prentice Hall. Upper Saddle River, New Jersey. Pages 189-190. or
sniper rifle A sniper rifle is a high-precision, long range shooting, long-range rifle. Requirements include high accuracy, reliability, mobility, concealment, and optics, for anti-personnel weapon, anti-personnel, anti-materiel rifle, anti-materiel and sur ...
s. Bullets classed as medium-velocity projectiles include those from
handgun A handgun is a firearm designed to be usable with only one hand. It is distinguished from a long gun, long barreled gun (i.e., carbine, rifle, shotgun, submachine gun, or machine gun) which typically is intended to be held by both hands and br ...
s,
shotgun A shotgun (also known as a scattergun, peppergun, or historically as a fowling piece) is a long gun, long-barreled firearm designed to shoot a straight-walled cartridge (firearms), cartridge known as a shotshell, which discharges numerous small ...
s, and
submachine gun A submachine gun (SMG) is a magazine (firearms), magazine-fed automatic firearm, automatic carbine designed to fire handgun cartridges. The term "submachine gun" was coined by John T. Thompson, the inventor of the Thompson submachine gun, to descri ...
s. In addition to causing damage to the tissues they contact, medium- and high-velocity projectiles cause a secondary cavitation injury: as the object enters the body, it creates a pressure wave which forces tissue out of the way, creating a cavity which can be much larger than the object itself; this is called "temporary cavitation". The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path. The characteristics of the tissue injured also help determine the severity of the injury; for example, the denser the tissue, the greater the amount of energy transmitted to it. Skin, muscles, and intestines absorb energy and so are resistant to the development of temporary cavitation, while organs such as the liver, spleen, kidney, and brain, which have relatively low tensile strength, are likely to split or shatter because of temporary cavitation. Flexible elastic soft tissues, such as muscle, intestine, skin, and blood vessels, are good energy absorbers and are resistant to tissue stretch. If enough energy is transferred, the liver may disintegrate. Temporary cavitation can be especially damaging when it affects delicate tissues such as the
brain The brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head (cephalization), usually near organs for ...
, as occurs in penetrating head trauma.


Location


Head

While penetrating head trauma accounts for only a small percentage of all traumatic brain injuries (TBI), it is associated with a high
mortality rate Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular Statistical population, population, scaled to the size of that population, per unit of time. Mortality rate is typically ...
, and only a third of people with penetrating head trauma survive long enough to arrive at a hospital. Injuries from firearms are the leading cause of TBI-related deaths. Penetrating head trauma can cause cerebral contusions and lacerations, intracranial hematomas, pseudoaneurysms, and arteriovenous fistulas. The prognosis for penetrating head injuries varies widely. Penetrating facial trauma can pose a risk to the
airway The respiratory tract is the subdivision of the respiratory system involved with the process of conducting air to the alveoli for the purposes of gas exchange in mammals. The respiratory tract is lined with respiratory epithelium as respiratory ...
and
breathing Breathing (spiration or ventilation) is the rhythmical process of moving air into ( inhalation) and out of ( exhalation) the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxy ...
; airway obstruction can occur later due to swelling or bleeding. Penetrating eye trauma can cause the globe of the eye to rupture or vitreous humor to leak from it, and presents a serious threat to eyesight.


Chest

Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%. Penetrating chest trauma can injure vital organs such as the heart and lungs and can interfere with breathing and circulation. Lung injuries that can be caused by penetrating trauma include pulmonary laceration (a cut or tear) pulmonary contusion (a bruise), hemothorax (an accumulation of blood in the chest cavity outside of the lung),
pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...
(an accumulation of air in the chest cavity) and hemopneumothorax (accumulation of both blood and air). Sucking chest wounds and tension pneumothorax may result. Penetrating trauma can also cause injuries to the heart and circulatory system. When the heart is punctured, it may bleed profusely into the chest cavity if the membrane around it (the
pericardium The pericardium (: pericardia), also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue (fibrous pericardium), ...
) is significantly torn, or it may cause pericardial tamponade if the pericardium is not disrupted. In pericardial tamponade, blood escapes from the heart but is trapped within the pericardium, so pressure builds up between the pericardium and the heart, compressing the latter and interfering with its pumping. Fractures of the ribs commonly produce penetrating chest trauma when sharp bone ends pierce tissues.


Abdomen

Penetrating
abdominal trauma Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness (medicine), tenderness, rigidity, and bruise, bruising of the external abdomen. Complications may include blood loss and infection. Diagnosis ma ...
(PAT) typically arises from stabbings, ballistic injuries (shootings), or industrial accidents. PAT can be life-threatening because abdominal organs, especially those in the
retroperitoneal space The retroperitoneal space (retroperitoneum) is the spatium, anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum ...
, can bleed profusely, and the space can hold a large volume of blood. If the pancreas is injured, it may be further injured by its own
secretion Secretion is the movement of material from one point to another, such as a secreted chemical substance from a cell or gland. In contrast, excretion is the removal of certain substances or waste products from a cell or organism. The classical mec ...
s, in a process called ''autodigestion''. Injuries of the
liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...
, common because of the size and location of the organ, present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. The intestines, taking a large part of the lower abdomen, are also at risk of perforation. People with penetrating abdominal trauma may have signs of
hypovolemic shock Hypovolemic shock is a form of Shock (circulatory), shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It can be caused by severe dehydration or blood loss. Hypovolemic shock is a medical emergency ...
(insufficient blood in the
circulatory system In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart ...
) and
peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...
(an inflammation of the
peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...
, the membrane that lines the
abdominal cavity The abdominal cavity is a large body cavity in humans and many other animals that contain Organ (anatomy), organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roo ...
). Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause bruits (a distinctive sound similar to heart murmurs) to be audible. Percussion of the abdomen may reveal hyperresonance (indicating air in the abdominal cavity) or dullness (indicating a buildup of blood). The abdomen may be distended or tender, signs which indicate an urgent need for surgery. The standard management of penetrating abdominal trauma was for many years mandatory
laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...
. A greater understanding of mechanisms of injury, outcomes from surgery, improved imaging and interventional radiology has led to more conservative operative strategies being adopted.


Assessment and treatment

Assessment can be difficult because much of the damage is often internal and not visible. The patient is thoroughly examined. X-ray and
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
ning may be used to identify the type and location of potentially lethal injuries. Sometimes before an X-ray is performed on a person with penetrating trauma from a projectile, a paper clip is taped over entry and exit wounds to show their location on the film. The patient is given
intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutr ...
fluids to replace lost blood. Surgery may be required; impaled objects are secured into place so that they do not move and cause further injury, and they are removed in an operating room. If the location of the injury is not obvious, a surgical operation called an exploratory laparotomy may be required to look for internal damage to the organs in the
abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
. Foreign bodies such as bullets may be removed, but they may also be left in place if the surgery necessary to get them out would cause more damage than would leaving them. Wounds are debrided to remove tissue that cannot survive and other material that presents risk for infection. Negative pressure wound therapy is no more effective in preventing wound infection than standard care when used on open traumatic wounds.


History

Before the 17th century, medical practitioners poured hot oil into wounds in order to cauterize damaged blood vessels, but the French surgeon Ambroise Paré challenged the use of this method in 1545. Paré was the first to propose controlling bleeding using
ligature Ligature may refer to: Language * Ligature (writing), a combination of two or more letters into a single symbol (typography and calligraphy) * Ligature (grammar), a morpheme that links two words Medicine * Ligature (medicine), a piece of suture us ...
. During the
American Civil War The American Civil War (April 12, 1861May 26, 1865; also known by Names of the American Civil War, other names) was a civil war in the United States between the Union (American Civil War), Union ("the North") and the Confederate States of A ...
,
chloroform Chloroform, or trichloromethane (often abbreviated as TCM), is an organochloride with the formula and a common solvent. It is a volatile, colorless, sweet-smelling, dense liquid produced on a large scale as a precursor to refrigerants and po ...
was used during surgery to reduce pain and allow more time for operations. Due in part to the lack of sterile technique in hospitals, infection was the leading cause of death for wounded soldiers. In
World War I World War I or the First World War (28 July 1914 – 11 November 1918), also known as the Great War, was a World war, global conflict between two coalitions: the Allies of World War I, Allies (or Entente) and the Central Powers. Fighting to ...
, doctors began replacing patients' lost fluid with salt solutions. With
World War II World War II or the Second World War (1 September 1939 – 2 September 1945) was a World war, global conflict between two coalitions: the Allies of World War II, Allies and the Axis powers. World War II by country, Nearly all of the wo ...
came the idea of blood banking, having quantities of donated blood available to replace lost fluids. The use of
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s also came into practice in World War II.


See also

* Aortic dissection *
Ballistic trauma A gunshot wound (GSW) is a penetrating trauma, penetrating injury caused by a projectile (e.g. a bullet) Shooting, shot from a gun (typically a firearm). Damage may include bleeding, bone fractures, organ (anatomy), organ damage, wound infectio ...
* Blunt splenic trauma * Blunt trauma personal protective equipment * Geriatric trauma * Pediatric trauma * Stab wound * Transmediastinal gunshot wound


References


External links

{{Authority control Medical emergencies Traumatology Injuries Trauma types