CTSU – Day Five: Surgical Case Studies

April 29, 2025 Daily

Gunshot Chest Trauma with Spinal Cord Injury: Clinical Case Breakdown and Teaching Notes

This clinical entry focuses on a patient with multiple gunshot wounds and spinal cord injury. The notes cover relevant pathophysiology, investigations, management, and anticipated complications. It is intended to provide a comprehensive, educational overview with practical relevance.

Case Presentation

A young male patient presents with four gunshot pellet wounds, located around the chest and abdomen. He is unable to move both lower limbs, with associated loss of sensation, and has reported epigastric pain and difficulty maintaining oxygen saturation (SpO₂).

He has a two-way Foley catheter (latex) in place.

Case Overview – A Double-Edge Trauma

Presentation Summary:

A young male patient presents with:

  • Multiple gunshot wounds to the chest and lower abdomen (notably epigastric region)
  • Inability to move both lower limbs + loss of sensation
  • SpO₂ not maintained on room air
  • Four visible pellet wounds
  • Urinary catheter in place
  • Pain at the epigastrium

This case combines two high-impact injuries:

  • Thoracic trauma (penetrating)
  • Spinal cord injury (neurological deficit)

Pathophysiological Explanation:

When a patient sustains a gunshot wound to the epigastric region or lower chest, pain becomes a functional barrier to deep breathing. The diaphragm’s descent becomes restricted due to:

  • Guarding (reflex muscular contraction to protect the area)
  • Pain-induced hypoventilation (shallow breathing)

This leads to:

  • Reduced alveolar ventilation
  • Atelectasis (alveolar collapse)
  • Ventilation/perfusion (V/Q) mismatch
  • Eventually desaturation even when oxygen is administered

Key Clinical Insight: Without adequate analgesia, respiratory mechanics are compromised. Patients begin to "splint" their chest — avoiding deep breaths — which can precipitate hypoxemia, infection, and delayed weaning from oxygen.

Teaching Analogy:

Think of the lungs like a sponge. If you press only the surface (shallow breath), the inner pores (alveoli) remain soaked (collapsed). Pain blocks full compression (deep breathing), and without air reaching those areas, they collapse (atelectasis).

Reporting SpO₂ Always state:

The mode of oxygen delivery (e.g., room air, nasal cannula, face mask)

Litres/min of oxygen given

Example: SpO₂ 93% on 5L/min via nasal cannula.

ABC Priorities and Vital Signs Interpretation

Initial Prioritization in a Trauma Setting:

Step Focus Key Action
A – Airway Patent? Cervical spine immobilization + Oropharyngeal suction if needed
B – Breathing Adequate chest movement? O₂ sat? Assess bilateral chest rise, insert chest tube if hemothorax/pneumothorax suspected
C – Circulation Hemodynamic status? Bleeding? Control external bleeding, assess pulses, IV fluids/blood

Pulse Rate and Hypovolemia:

The elevated pulse rate in this patient could stem from:

  1. Hypovolemia: Due to internal/external hemorrhage from gunshot wounds.
  2. Sympathetic overdrive (Fight or flight): Pain, anxiety, and trauma surge catecholamine levels.
  3. Compensatory Tachycardia: The body attempts to maintain perfusion pressure despite blood loss.

Clinical Note: A rapid pulse in the presence of trauma should always raise suspicion of ongoing blood loss, even if external bleeding is not obvious. Look for signs like:

  • Cool extremities
  • Delayed capillary refill
  • Dizziness, fainting spells

Red Flag: Profuse Bleeding

If profuse bleeding is noted in the patient's history or on scene:

  • The rate of bleeding matters. Gunshot wounds can disrupt large vessels or cause cavitation and tissue shredding.
  • Assess estimated blood loss and correlate with class of hemorrhagic shock.

Hemorrhagic Shock Classification Table:

Class Blood Loss Heart Rate BP Mental Status Urine Output
I <15% Normal Normal Alert >30 mL/hr
II 15–30% >100 Normal Anxious 20–30 mL/hr
III 30–40% >120 Decreased Confused 5–15 mL/hr
IV >40% >140 Very Low Lethargic Minimal

In this patient, dizziness and fainting spells suggest at least Class II–III shock. Manage aggressively with IV fluids and consider transfusion.

Clinical Considerations for Spinal Cord Injury and Gunshot Wounds

Gunshot Wounds and Imaging

Due to retained pellets:

MRI is contraindicated CT Scan is preferred

Imaging in the Presence of Embedded Pellets

MRI is contraindicated for patients with metallic foreign bodies such as embedded gunshot pellets, due to the following risks:

  1. Ferromagnetic Risk
    The strong magnetic field in MRI can cause metallic objects to:

    • Move or shift, leading to possible internal injury (e.g., vascular or neurological damage).
    • Heat up, causing burns to the surrounding tissues.
    • Distort MRI images, making it difficult to get an accurate diagnosis.

  2. Clinical Risks

    • If the pellet is located near critical structures (e.g., blood vessels, spinal cord), MRI could exacerbate the injury by causing the pellet to migrate, leading to more severe neurological deficits or bleeding.
    • Spinal cord injury may worsen if a metallic object shifts within the canal during MRI.

What to do instead:

  • CT Scan (best imaging modality in this case): Provides excellent detail of the bony structure and foreign body location, and can help assess the trajectory of the pellet in relation to anatomical structures.
  • X-rays: Useful for quick localization of the metallic fragments and initial evaluation in an emergency setting.

Mnemonic to Remember Imaging Contraindication
"MAG-PULL"

  • Metallic
  • Artifact
  • Gunshot
  • Pellet
  • Use
  • Low-radiation
  • Localization via CT

Conclusion:
MRI should never be used in patients with embedded metallic pellets. CT spine is the optimal choice for this patient's condition.

Transporting the Trauma Patient

Use log roll technique, and place patient on a spinal board to prevent further spinal injury.

Management of Spinal Cord Injury

Traumatic Spinal Shock

Spinal shock occurs due to the disruption of nerve supply below the level of injury, leading to a state of hypotension and hypoperfusion. This is primarily caused by unopposed parasympathetic nervous system (PSNS) activity following loss of sympathetic tone, resulting in massive vasodilation.

  • Pathophysiology:
    Loss of sympathetic outflow leads to vasodilation and subsequent hypotension. The PSNS is not countered by sympathetic stimulation, leading to an unbalanced autonomic response. This results in reduced systemic vascular resistance and bradycardia, which can worsen the patient's circulation.

  • Management:
    Fluid resuscitation with IV fluids (preferably isotonic solutions) is key to restoring blood volume and maintaining perfusion. Vasopressors may be necessary if the hypotension persists after fluid boluses.

Respiratory Complications

  • Atelectasis
    If the patient is not adequately managed for pain, atelectasis may occur. Pain from chest trauma, especially gunshot wounds, can prevent effective coughing and deep breathing, leading to the collapse of lung tissue. Stasis of secretions is a risk factor for respiratory tract infection.

    Management:

    • Adequate analgesia to promote deep breathing and coughing.
    • Incentive spirometry to encourage lung expansion and reduce atelectasis.
    • Chest physiotherapy as needed to clear secretions.

Bowel and Bladder Management

Constipation and Paralytic Ileus

A common complication in spinal cord injury is paralytic ileus, where there is temporary loss of bowel motility due to disrupted autonomic regulation. In the early phase, the enteric plexus is impaired, causing a lack of peristalsis.

Medications:

Drug Use
Dulcolax (bisacodyl) Rectal stimulation
Erythromycin Motilin agonist
Metoclopramide Prokinetic agent

Once the enteric nervous system begins to recover, peristalsis will resume, and patients may experience incontinence.

Urinary Retention and Incontinence

In the early phase after a spinal cord injury, patients may experience urinary retention due to loss of bladder tone. Over time, urinary incontinence may develop as reflexes are restored.

  • Management:
    • Catheterization (preferably a Foley catheter) should be done early to prevent urinary retention and renal damage.
    • Bladder training and potential use of anticholinergic agents can help manage the incontinence later on.

Pressure Ulcers (Bedsores)

  • Preventive Measures:

    • The most critical step in pressure ulcer prevention is frequent repositioning (at least every 2 hours) to relieve pressure from the skin.
    • Specialty mattresses like air or water beds can help distribute pressure more evenly.
    • Skin care: Ensure the patient’s skin is clean and dry, and use appropriate moisturizers to prevent maceration.

  • Why is this important?
    Bedsores, if not managed properly, can lead to recurrent infections and sepsis, compromising the patient’s recovery process and ultimately their ability to regain mobility.

DVT Prophylaxis

Immobility due to spinal cord injury places the patient at risk for deep vein thrombosis (DVT), which can lead to pulmonary embolism.

  • Management:
    • Low-dose heparin or enoxaparin for anticoagulation.
    • Mechanical prophylaxis like compression stockings or intermittent pneumatic compression devices.
Measure Notes
LMWH (e.g., Enoxaparin) First-line
Compression stockings Adjunctive
Early physiotherapy Mobilization as tolerated

Long-Term Complications

  • Muscle Wasting and Atrophy
    Prolonged immobility leads to disuse atrophy, where muscles shrink and lose strength due to lack of use.

  • Joint Contractures
    Spinal cord injuries can result in joint contractures, particularly if the patient is not properly positioned or moved frequently.

  • Spasms
    Some patients may develop spasticity in the muscles below the level of injury, which can interfere with rehabilitation.

Management:

  • Physiotherapy

  • Supportive psychotherapy

  • Depression
    Chronic illness and loss of function may lead to depression. Management involves psychological support and family counseling.

Conclusion: Does the Patient Need Surgery?

Yes, surgery may be indicated to stabilize the spine, especially if there is a fracture or dislocation of the vertebrae. Surgery is often considered in younger patients to facilitate early mobilization and reduce the risk of future complications.

  • Goal: Stabilizing the spine allows for better rehabilitation and reduces the risk of secondary complications (e.g., further neurological deterioration).

5. Management of Chest Trauma: Gunshot Wound to the Chest

Pathophysiology of Chest Trauma

Gunshot wounds to the chest can cause a variety of injuries, from simple pneumothorax to hemothorax, cardiac tamponade, and vascular injury. The mechanical force from the bullet and any accompanying fragments can cause rib fractures, tissue lacerations, and damage to vital organs such as the lungs, heart, and great vessels.

  • Pneumothorax: Air enters the pleural space, causing the lung to collapse.
  • Hemothorax: Blood collects in the pleural cavity due to vascular injury.
  • Cardiac Tamponade: Blood accumulates in the pericardial sac, impairing the heart’s ability to pump effectively.

This type of trauma requires immediate and thorough assessment to determine the severity of the injury.

Immediate Management and Assessment

  1. Airway, Breathing, Circulation (ABCs)
    The first step in trauma management is always to ensure patent airways. A jaw thrust maneuver may be necessary if there is neck trauma, especially if there’s a risk of cervical spine injury.

  2. Oxygenation
    A high-flow oxygen mask should be used to maintain adequate oxygenation. In this case, monitoring the oxygen saturation (SpO2) is critical.

    • Oxygen Saturation Reporting:
      • Always specify whether the patient is on room air or if they are receiving supplemental oxygen.
      • If the patient is on high-flow oxygen, it’s important to state the liter flow rate (e.g., 15L/min) to contextualize the SpO2 reading.
      • If Fio2 (fraction of inspired oxygen) is not reported, it’s impossible to assess whether the oxygen therapy is adequate.

  3. Pain Management
    Adequate analgesia is essential in any trauma patient. Failure to adequately manage pain may lead to respiratory depression, atelectasis, and hypoxia, worsening the patient’s overall condition.

    • Morphine or fentanyl are commonly used to control pain in traumatic injuries.
    • In cases of severe chest trauma, epidural analgesia may be considered if the pain is unmanageable through systemic narcotics.

Types of Gunshot Wounds to the Chest

The trajectory and impact of a gunshot wound depend on various factors:

  • Pellet size and type: Larger pellets (e.g., shotgun) create more significant tissue damage compared to small caliber bullets.
  • Entry and exit wounds: Entry wounds are typically smaller, while exit wounds are larger and more irregular.

Pellet Wounds:

  • Pellets can be lodged in the chest cavity, leading to hemothorax or pneumothorax.
  • The patient may present with dyspnea, tachypnea, hypotension, and shock.

Clinical Signs:

  • Tachycardia and hypotension are often signs of shock due to bleeding (hemothorax).
  • Crepitus on palpation of the chest wall may indicate pneumothorax.

Pneumothorax vs. Hemothorax: How to Differentiate

Pneumothorax:

  • Clinical signs:

    • Sudden sharp chest pain (often unilateral)
    • Dyspnea (due to collapsed lung)
    • Hyper-resonance on percussion
    • Decreased breath sounds on auscultation of the affected side
    • Tracheal deviation towards the unaffected side in large pneumothorax

  • Management:

    • Needle decompression (thoracostomy) followed by a chest tube placement to evacuate the air.

Hemothorax:

  • Clinical signs:

    • Severe chest pain
    • Dyspnea (due to blood accumulation in the pleural space)
    • Dullness on percussion over the affected side
    • Decreased breath sounds due to blood in the pleural space

  • Management:

    • Chest tube insertion to drain the accumulated blood.
    • If massive hemothorax (more than 1.5L of blood), consider surgical intervention (e.g., thoracotomy).

Mnemonic to remember:

  • Pneumo = Air (hyper-resonance)
  • Hemo = Blood (dullness)

Scenario:

Patient presents with unilateral decreased breath sounds after gunshot injury.

Finding Pneumothorax Hemothorax
Percussion Hyperresonant Dull
Breath sounds Decreased/Absent Decreased
Tracheal deviation Away from tension side Possible if massive
Neck veins Distended (if tension) Flat (hypovolemia)
CXR Collapsed lung, air space Blunting of costophrenic angles

Pleural Effusion — Clinical Findings

  • Dullness to percussion
  • Decreased breath sounds
  • Decreased tactile fremitus
  • Egophony at upper border

Wound Care and Dressing

A patient with a gunshot wound to the chest should have the wound assessed for:

  • Size: Report the size of the wound in centimeters.
  • Type: Is the wound a clean entry, or is it complex (i.e., involving soft tissue damage or bone injury)?

Dressing:

  • Apply a sterile occlusive dressing to seal the wound and prevent air from entering the pleural space in the case of a sucking chest wound.
  • Consider antibiotics to prevent infection, especially if the injury involves contamination (e.g., from clothing or debris).

Management of Hemorrhage and Shock

The patient may present with hypovolemic shock due to massive hemorrhage from the chest trauma.

  • Initial fluid resuscitation with crystalloids (e.g., normal saline or Ringer's lactate) is essential.
  • Blood transfusion may be required if the patient shows signs of severe blood loss.
  • Use the ABO compatibility test for crossmatching blood and administering group O negative blood as a universal donor if there’s no time for crossmatching.

Case Conclusion and Next Steps

  • Oxygen therapy, analgesia, and fluid resuscitation should be prioritized in this trauma patient.
  • CT scan is the preferred diagnostic tool to assess the gunshot wound and any associated injuries (e.g., hemothorax or pneumothorax).
  • Thoracostomy or chest tube insertion may be required for managing a pneumothorax or hemothorax.
  • Surgical intervention (e.g., thoracotomy) is indicated if there is massive bleeding or significant organ damage.
  • Close monitoring in the ICU for respiratory and circulatory status is essential.

6. Long-Term Management and Rehabilitation

Once the immediate life-threatening injuries have been managed, the focus shifts to long-term rehabilitation:

  • Physical therapy: Early mobilization and rehabilitation are key to preventing contractures and maintaining muscle strength.
  • Psychosocial support: Given the traumatic nature of the injury, psychotherapy and family counseling are essential to address any psychological distress (e.g., depression).

Neurological Assessment

  • Upper limb power: 5/5 across all joints
  • Grip strength: Check palm grip
  • Lumbricals: Insert a sheet between fingers and ask the patient to hold while you pull

Dermatomal Map: Refer to standard dermatomal distribution charts for sensory evaluation.

Foley Catheters

Types:

Type Material Duration Notes
Foley (2-way) Latex ~4 weeks Common; cheaper
Foley (2-way) Silicone ~2 months Use in latex allergy
Foley (3-way) Latex/Silicone Special cases For bladder irrigation

Indications for 3-way catheter:

  • Gross hematuria requiring irrigation
  • Continuous bladder wash

Catheter Complications:

  • Encrustation and stone formation
  • Urethral trauma
  • Infection (CAUTI)
  • Bladder spasms

Stress Ulcer Prophylaxis

Especially with brain or spinal cord injury.

  • Drug of choice: Omeprazole (PPI)

Case 2: Gunshot Wound to the Chest (Refer to yesterday's note)

If CSF Rhinorrhea or Otorrhea → Think Basilar Skull Fracture

Finding Location Explanation
CSF Rhinorrhea Cribriform plate (anterior cranial fossa) Close to nasal cavity
CSF Otorrhea Petrous temporal bone (middle cranial fossa) Close to ear canal

Lucid Interval in Epidural Hematoma

Why?

  • Middle meningeal artery rupture → rapid arterial bleed
  • Initial loss of consciousness → temporary compensation
  • Then decompensation as mass effect increases → Lucid interval

Trimodal Pattern of Death in Trauma

Timeframe Description
Immediate First few minutes — massive brain or vessel trauma
Early Minutes to hours — ATOM-FC
Late Days to weeks — sepsis, multiorgan failure

Mnemonic: ATOM-FC

  • A: Airway obstruction
  • T: Tension pneumothorax
  • O: Open pneumothorax
  • M: Massive hemothorax
  • F: Flail chest
  • C: Cardiac tamponade

Edema Grading

Grade Description
1+ Barely perceptible indentation
2+ Mild, rebounds in <10 seconds
3+ Moderate, rebounds in 10–20 seconds
4+ Severe, rebounds in >20 seconds

Impalement Wound

Definition:
An impalement wound occurs when a foreign object penetrates and remains lodged within the body—commonly wood, metal rods, or bone fragments. The object’s in situ status differentiates it from typical penetrating wounds and necessitates unique management protocols.

Classification:

  • Type I (In situ): The object remains embedded at the time of clinical presentation.
  • Type II (Pre-hospital removal): The object was removed before medical evaluation—often resulting in uncontrolled bleeding, tissue collapse, and worsened outcomes.

Clinical Considerations:

  1. Do NOT remove the object in the field:
    Removal may eliminate the tamponade effect, causing catastrophic hemorrhage and worsened organ/tissue disruption.

  2. Stabilize the object:
    Apply bulky dressings or padding around the object to prevent shifting during transport. Avoid circumferential dressings—these can induce torsion and shear.

  3. Hemorrhage control:
    Apply pressure to surrounding wound margins, never on the object itself.

  4. IV access & resuscitation:
    Establish at least two large-bore IV lines, preferably proximal to the injury. Begin isotonic fluids and crossmatched blood products as needed.

  5. Imaging:

    • Plain X-rays: Rapid localization, trajectory assessment.
    • CT scan (preferred): Defines involvement of vital structures, vascular proximity, and deep tissue injury.
    • MRI: Contraindicated if metal is involved due to risk of displacement or heating.

  6. Antibiotics & Tetanus Prophylaxis:

    • Start broad-spectrum IV antibiotics covering skin flora and anaerobes (e.g., cefazolin + metronidazole).
    • Update tetanus immunization per CDC guidelines.

  7. Surgical Management:

    • Always performed in the operating theatre under controlled settings.
    • Includes foreign body extraction, wound exploration, debridement, vascular repair, and drainage as needed.

Mnemonic: STUCK for Impalement Wound Care

Letter Action
S Stabilize object in place
T Transport urgently to facility
U Use imaging (X-ray/CT)
C Control bleeding at margins
K Keep object until OR removal

Wound Description (Example)

12 cm wound, well apposed, no signs of infection, healing appropriately

Michelin Man Sign (Subcutaneous Emphysema)

Description:

The “Michelin Man” sign refers to the striking appearance of subcutaneous emphysema, where air tracks under the skin—often around the neck, chest, and face—causing swelling and a crackling sensation on palpation (crepitus). The name is derived from the appearance of the tire company mascot with rounded air-filled contours.

Causes:

  • Traumatic pneumothorax (especially open or tension types)
  • Tracheobronchial injury
  • Esophageal rupture (e.g., Boerhaave syndrome)
  • Chest tube misplacement
  • High-pressure ventilation (barotrauma)

Clinical Implications:

  • Air can track to the mediastinum → pneumomediastinum
  • Can compromise airway and venous return if extensive
  • Signals underlying thoracic injury needing urgent imaging

Diagnosis:

  • Chest X-ray: May show lucent streaks in soft tissue
  • CT scan: Precise delineation of air spread

Management:

  • Treat underlying cause (e.g., chest tube for pneumothorax)
  • Oxygen therapy (enhances nitrogen resorption)
  • In severe cases: blowholes (skin incisions) may be used to decompress

Why You Close Chest Wounds Even If Indeterminate

Principle:

The chest is the ONLY place you actively close an indeterminate wound (unlike abdomen or head) due to the risk of open pneumothorax—a life-threatening condition where air enters the pleural cavity during inspiration but cannot escape, collapsing the lung.

Pathophysiology:

  • Sucking chest wound creates a direct air path into pleural space.
  • If the wound is larger than the tracheal diameter, air preferentially enters via the chest wall.
  • This impairs ventilation and causes lung collapse.

Management:

  1. Three-Sided Occlusive Dressing:
    • Seals the wound on 3 sides.
    • Allows air to exit during exhalation but prevents entry on inhalation.
  2. Chest Tube Placement:
    • Inserted away from the wound site to evacuate residual air.
    • Prevents development of a tension pneumothorax.
  3. Definitive Surgical Closure:
    • Performed after stabilization and imaging.

NEVER tightly close a penetrating abdominal wound in the ED unless under surgical control—doing so may trap infected material or blood.

Types of Wounds and Their Management

Wound Type Description Management Strategy
Clean Surgical or traumatic wound with no contamination Primary closure with sterile technique
Clean-contaminated Enters GI, respiratory, or genitourinary tract without gross contamination Close primarily with prophylactic antibiotics
Contaminated Gross spillage from hollow viscus, or traumatic wounds <6 hours old Debridement + delayed primary closure or secondary intention
Dirty/infected Traumatic wound >6 hours, devitalized tissue, purulence present Leave open, perform serial debridement, allow secondary healing or skin grafting later
Avulsion Tissue torn away; skin flaps may remain Clean thoroughly, debride devitalized areas, flap repair if possible or secondary healing
Puncture Deep narrow track wound (e.g., nails, splinters) High infection risk → do not suture; irrigate, assess for foreign body, tetanus prophylaxis, consider delayed closure
Impalement Object remains lodged in the wound Stabilize object, do NOT remove in field, imaging, surgical removal in OR
Gunshot wound (GSW) High-velocity projectile; can create cavitation and distant tissue damage Assume underlying injury; control bleeding, tetanus prophylaxis, imaging, surgical exploration depending on location and hemodynamic stability
Blast injury Combination of blunt, penetrating, and burn mechanisms Assess for primary (barotrauma), secondary (shrapnel), tertiary (blunt trauma), and quaternary (burn, inhalation) effects
Degloving Skin and subcutaneous tissue stripped off underlying fascia Extensive debridement, vacuum-assisted closure (VAC), skin grafting or flap reconstruction

Indeterminate Wound

An indeterminate wound is a traumatic injury in which the depth, trajectory, or internal involvement cannot be accurately assessed on initial inspection. These wounds carry a high risk of concealed damage to vital structures or cavities and require a cautious, investigative approach.

Definition

A wound whose external characteristics do not reliably indicate the extent of internal damage, especially regarding penetration into major cavities (e.g., thorax, abdomen, skull).

Characteristics

  • Unclear depth: Cannot determine how deep the wound travels.
  • Uncertain trajectory: May have taken an unusual path, potentially into vital structures.
  • Hidden injury risk: May involve vasculature, hollow organs, or other critical anatomy without overt signs.
  • Common causes: Stab wounds, gunshot wounds, blast injuries, impalements.

Clinical Examples

Wound Location Clinical Concern Management Approach
Chest Open pneumothorax risk if left unsealed Apply 3-sided dressing to temporarily close
Abdomen Risk of hollow viscus or vascular injury Leave open; explore surgically
Skull Possibility of dural tear or brain trauma Imaging + neurosurgical consult
Neck High density of vessels, airway, esophagus Zone-based imaging and surgical planning

Mnemonic — "IF IT LOOKS SMALL, IT MAY STILL KILL"

Because surface size does not reflect internal danger.

Counterparts: Types of Wounds by Clarity

Wound Type Description
Indeterminate Depth/trajectory uncertain; possible internal injury not evident externally. Requires imaging/exploration.
Penetrating Clearly enters the body and pierces through skin and possibly deeper structures. Trajectory is evident.
Perforating Has both an entry and exit wound; object has passed completely through the body part.
Superficial Limited to the skin or subcutaneous tissue. Depth and extent clearly visible and typically benign.
Impalement Foreign object remains lodged inside the wound. Trajectory may or may not be clear; requires stabilization and surgical removal.

Why You Close Chest Wounds (Exception)

The chest is the only anatomical region where an indeterminate wound is temporarily closed in the field. This is to prevent an open pneumothorax (sucking chest wound), which allows air to enter the pleural space during inspiration, causing lung collapse.

Management:

  • Apply a 3-sided occlusive dressing:
    • Seals during inhalation
    • Allows air to escape during exhalation
  • Do NOT seal all 4 sides — may cause a tension pneumothorax.

Takeaway

Treat all indeterminate wounds as potential entry points into body cavities until imaging or exploration confirms otherwise. When in doubt, don’t close — unless it’s the chest, and even that has rules.

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