by David Page
Suddenly your character's car rattles off the road and crashes into a double-wide. Her chest smashes into the steering wheel. Directly behind her sternum lies her heart, which, in this steering wheel injury, is bruised. For the moment, we're interested in only one of the consequences of blunt chest trauma: flooding of the pericardial sac with blood.
It's referred to as cardiac tamponade.
A stab or gunshot wound to the anterior chest will often result in a cardiac tamponade, as will a major injury to the heart. In both penetrating and blunt chest trauma, the doctor should consider the possibility of a pericardial sac full of blood. It doesn't take a lot of blood to squeeze the pump into failing.
Do you have a doctor character who's pretty smart? (They're not all clever, you know.) OK, this is how he picks up (that's doctor talk for "diagnoses") a cardiac tamponade everyone else in the ER missed. He examines the victim's chest and notices what is called Beck's Triad:
1. Muffled or distant heart sounds. There's now a wall of blood between the heart valves (which are making the noises he wants to hear) and the chest wall.
2. Narrowing of the two blood pressure numbers. Because the heart can't fill and empty as well, the maximum and minimum pressures are closer together; instead of 120/80, blood pressure might be 90/70.
3. Enlargement or distention of the neck veins. Blood is "backed up" in the big veins because the heart is less efficient while trapped inside the pericardial sac.
The doctor inserts a huge needle between the ribs near the breastbone directly into the pericardial sac and removes (aspirates) the blood squeezing the heart.
Injuries That May Kill Within Hours
Lung Bruise
Most commonly associated with blunt chest trauma, a lung bruise is an area where blood and fluid collect within air sacs and interfere with oxygenation. If the bruise is small, it will heal spontaneously. If it's massive, your victim may require intensive care on a ventilator. It may take weeks to heal. The injury may even progress to the point where the lung tissue becomes solid—like liver.
Any degree of disability your story requires may be created by a whack in the ribs. A bunch of ribs may be busted. These fractures may be the usual one-crack-per-rib variety or they may become broken in two places producing a flail chest. Still, the ribs aren't the problem. They heal with rest. It's the ugly underlying lung bruise that can sneak up on your heroine and strangle her oxygen supply. Treat it with a ventilator, diuretics (IV water-pill-type drugs to dry out the lungs) and antibiotics if needed.
Heart Bruise
All you need to remember about this injury is that it's exactly like a heart attack. That's correct. A heart attack means a patch of cardiac muscle died beyond a blockage in one of the coronary arteries. In the case of a bruise, the muscle is injured by impact, but it dies nonetheless. As with a lung bruise, the heart is not very creative and, regardless of the cause of the injury, the tissue response is always the same.
If the patch is huge, cardiogenic shock occurs: The pump fails to propel enough blood to the body's vital tissues. Your character's now in big trouble, and special cardiac drugs are needed to support heart function. For lesser injuries, the patient is treated like a heart attack victim— with rest, medications and a graduated exercise program.
Torn Aorta
Not much imagination is needed to create this potential disaster. This huge blood vessel comes off the heart and is attached by a ligament to the chest wall as it arches over and down toward the back of the chest cavity. Now imagine, after a decelerating impact your character's aorta continuing in a straight line according to Newton's first law of motion— until it's acted upon by that little ligament, which tears the pulsating blood vessel.
You'll recall that this is one of the causes of immediate death at the scene of the accident. But that's only if the full thickness of aorta tissue rips open, pouring the victim's entire blood volume into his chest cavity. Often these trauma victims arrive in the ER in shock from bleeding from this injury or from hemorrhage from other impacts. Because the smaller tear is only partial thickness, the remaining tube holds and the victim lives until your hero either makes or misses the diagnosis.
The middle compartment of the chest is the mediastinum and contains the heart and great blood vessels. So the red flag with blunt chest trauma—particularly a steering wheel injury—is a widened mediastinum on chest x-ray. To prove the aorta is torn, your character orders an arteriogram, an x-ray of the heart and aorta performed with special dye. If dye leaks out of the blood vessel, there's a tear in there somewhere.
Torn Diaphragm
You'll remember the diaphragm is the muscular sheet that separates the chest from the abdominal contents. It looks like a parachute with the strings anchored to the walls inside the belly. It helps you breathe and is traversed by the aorta heading south with fresh blood and the vena cava, the huge abdominal vein, returning old blood from the lower body to the heart. Also, your esophagus (gullet) passes through the diaphragm.
Injury to the diaphragm can be subtle. As with an aortic tear, a ruptured diaphragm is suggested by a chest x-ray that shows fluid or intestine in the left chest. Blunt trauma causes the diaphragm to "burst" with a large radial tear, whereas penetrating wounds, e.g., from a knife stab, cause small holes.
Often the diagnosis isn't made until weeks or months later when the chest x-ray doesn't improve or a trapped loop of intestine causes bowel obstruction (blockage). You can use this injury to get someone out of the picture again after his convalescence from the original accident is over.
Torn Windpipe
Do you have a karate expert in your story? Suppose she defends herself by striking her attacker in the throat. He becomes hoarse and develops crackles in the tissues of his neck. A grating sound is produced when someone pokes his neck, which is now swelling.
He's got a broken voice box, a fractured larynx.
Chest trauma may burst the windpipe lower down or even rupture one of the branches (bronchi) of the windpipe. This may cause labored breathing, depressed level of consciousness or a tension pneumothorax. The doctor makes the diagnosis by looking into the windpipe and its branches (bronchoscopy).
Immediate surgical repair is mandatory.
Torn Gullet
This one's both dull and fascinating.
By now you need little imagination to picture a long kitchen knife slicing between the victim's ribs, penetrating the back of the chest cavity, narrowly missing the aorta but nicking the esophagus. Saliva, bacteria, booze and food drip into the sterile chest cavity, and if the injury is missed, the patient can insidiously slip into sepsis, an infected state with fever, pus formation and an urgent need for surgery.
It's subtle. It's a useful "missed diagnosis" ticking clock.
Now here's the really fascinating possibility. (Hopefully, you've blunted any tendency toward squeamishness by this point.) Suppose you've got a character who has just been admitted to the hospital with pneumonia. Two days later, he slips into shock from infection and his chest x-ray looks horrid. Finally, the doctor asks him how this all started (doctors are supposed to take the history first, but being as smart as they are, they often make the diagnosis first, and when it's wrong, they go back and do it right the second time around—don't tell anyone). Your character mentions that the left chest pain started when he began to forcefully vomit. The upper GI x-ray the doctor now orders shows a huge hole in the esophagus. Yep. Violent retching tore a hole in his esophagus, and he vomited into his left chest cavity!
This injury is treated by surgical repair of the hole and placement of a chest tube. It begins with left chest pain, is often confused with left-sided pneumonia and may require weeks of recovery. And if you have to know, it's called Boerhaave syndrome.
There they are: the dirty dozen. And a bonus.
All potentially lethal, these severe injuries may be successfully treated and serve your story by creating intrigue, tension and conflict. Of course, you can have your character inju
red less severely.
It should be clear by now that a gunshot wound of the chest may cause any of these injuries (or ones very similar), as depicted in Figure 12, including a wound in the heart. A quarter of the victims of a blast into the heart actually survive surgery and go on to battle once more. This is another reason why the chest is opened in the ER as an acute surgical emergency.
Don't forget that the other chest injuries that require only a chest wrap or splinting are rib bruises and simple rib fractures. Keep the fractures low in the chest. Upper rib fractures are associated with the dirty dozen.
Also, remember to use this material sparsely. Imply what you don't describe.
Next, we'll discover that some so-called chest injuries are actually a problem in the belly.
Unlike the chest wall propped up like a mountaineering tent by rib struts, the abdominal wall is soft, pliable, vulnerable. Gentle curves and powerful muscles mask injuries, conceal bleeding and confuse the doctor who attempts to diagnose a belly injury. In fact, it is so difficult to identify abdominal cavity problems (called intra-abdominal injuries) that most medical texts beg the physician who initially sees the patient to cultivate a high index of suspicion.
A trauma surgeon is ready for any kind of belly injury. For example, if a victim of a street fight comes to the ER in shock, one of the first places on the belly wall the surgeon examines is the right upper quadrant. Why? Because when a knife is employed in a premeditated attack, a right-handed assailant typically grasps the weapon with the blade pointing up. Then, he rips up and in, smack into the right upper quadrant— and the liver. (By contrast, someone attacking out of sudden, blind rage is more likely to jab downward, holding the knife point down.)
Here's good news for the writer. Unlike the specific and rather complicated injuries you learned about in the previous chapter, belly trauma is easier to understand because most abdominal organs become injured in the same way. Instead of listing a dozen quite distinct injuries, we'll be looking first at a method of understanding all intra-abdominal trauma no matter which organ is involved.
Patterns of Intra-Abdominal Injury
Two types of intra-abdominal organs make up the belly contents—hollow and solid—and so only two basic patterns of injury can occur. Most of these organs have something to do with digestion, although the kidneys, spleen and reproductive organs are also implicated in trauma. Before examining specific organ trauma, which you know as an internal injury—a nebulous collection of terrible things only the doctor is allowed to see—we'll first look at how hollow and solid organs become smashed up.
Hollow Organ Damage
A long time ago, "living tubes" became necessary to permit the concept of a multiorgan human, a complex living creature distinguished from single-cell globs by complex internal support systems. Living tubes carry a variety of fluids (and some notable solids) about the body. If injured, these tubes leak, bleed or become gangrenous.
As Figure 13 (page 100) explains, the basic living tube unit consists of an artery carrying blood to the tube, veins transporting old blood away, and the tube. With both blunt and penetrating trauma, the artery and vein (being close to each other) are often injured as one. Thus, the three basic patterns of injury are:
1. Cut or torn blood vessels that hemorrhage
2. Cut or torn blood vessels that leave the tube without a blood supply, resulting in dead tissue, or gangrene
3. A cut or tear to the tube (a traumatic hole called a perforation) resulting in body fluid leak
Solid Organ Damage
The human body specialized by developing solid organs that assist in the various survival functions of excretion, digestion and procreation—all tied together by the heart, lungs and a massive tree of branching blood vessels. Many solid organs have more than one role. When injured, these solid organs and their special functions become compromised. Thus, loss of organ function is a possibility.
Figure 14 (page 101) depicts a working model for a solid organ and its injuries. Again, the artery carries blood to the organ while veins permit old blood to exit. Most solid organs have the consistency of liver, and the basic injuries to these organs are:
1. Cut or torn blood vessels that hemorrhage
2. Cut or torn blood vessels that leave the organ without a blood supply, resulting in partial or complete organ necrosis (means dead tissue, as in necrotic liver, and is pretty much the same as gangrene)
3. Cut or shattered organ tissue, resulting in hemorrhage
4. Leakage of specific body fluids
At first you might think blunt trauma is less destructive than a penetrating
Abdominal Trauma: Beware of Hidden Damage / 101
injury. Not necessarily so. Gunshot and other missile wounds to the belly do cause all sorts of unpredictable havoc, but blunt impacts destroy tissue as well.
Blunt Trauma to the Abdomen
Solid Organs
Liver: The biggest organ in the body other than the skin, the liver serves as the body's waste scrubber as well as the producer of essential body chemicals and other vital substances. Blunt trauma to the right side of the lower ribs or abdomen results in various types of liver lacerations. Some are innocent and require no treatment; others cause a "burst" liver where the tissue literally explodes and hemorrhages so badly that survival is barely possible. In-between degrees of liver damage are often seen and require suturing to control bleeding.
Spleen: Unlike the liver, the spleen may be salvaged even if it is split
Master Injury List For the Abdomen
Blunt Abdominal Trauma Solid Organs
■ Liver laceration
—Major: remove shattered parts, tie off blood vessels —Minor: observe with repeated CT scans and blood counts
■ Ruptured spleen
—Major: remove spleen —Minor: repair spleen
■ Pancreas
—Bruised: observe or drain —Lacerated: remove injured segment and drain Hollow Organs
■ Bladder: repair; drain with suprapubic catheter
■ Small intestine:
—Major: remove segment and sew back together —Minor: observe
■ Colon/rectum
—Major: remove segment, perform a colostomy (temporary) —Minor: observe
■ Kidney
—Major: remove all or part —Minor: observe
Penetrating Abdominal Trauma Solid Organs
■ Liver, spleen, pancreas, kidney
—Knife trauma: clean (debride), drain and conserve tissue —Gunshot: clean extensively and remove dead tissue (bullet damages tissue beyond immediate track), drain extensively Hollow Organs
■ Small intestine: remove any damaged part and sew together (called an anastomosis of the bowel)
■ Colon/rectum: extensive removal of any torn tissue, may close small holes but remove segment; always a protective colostomy
in two after major trauma. Surgeons always make an attempt to preserve this portion of the body's immune system. At times, a chunk is removed surgically and the remaining portion saved with its blood supply.
A ruptured spleen occurs with trauma to the left side of the body, either to the lower ribs or flank. Hiding under the protective shield of the tenth, eleventh and twelfth ribs, the spleen may be split open by a hockey check, from a fall on slippery sidewalk ice, or after what seemed to be an innocent tumble at home, particularly if the spleen is abnormally enlarged. The victim will suffer from light-headedness, will become pale and may slip into shock from blood loss.
What happens next?
Anything you want. Her coagulation system can kick in and eventually stop the bleeding, or you may choose to let her ooze and ooze until hospitalization and multiple transfusions are needed. Even if she does stops hemorrhaging initially, she may start bleeding uncontrollably later.
A ruptured spleen serves as a flexible plot tool in your devious hands.
Pancreas: A soup bowl full of enzymes is produced each day by the pancreas, the firm organ tucked beh
ind the stomach. Attached to the duodenum (of ulcer fame) by a duct (tube), the gland's secretions are designed to digest protein, carbohydrates and fats. Also, the pancreas possesses scattered little islands of cells that produce insulin.
Even trivial injuries are poorly tolerated by the pancreas. If you need someone hurt by an innocent assault, for example, a playful punch in the gut, give the poor dolt a bruised pancreas and three months of lingering near death in the ICU from progressive multiple organ failure.
Leaking pancreatic enzymes can autodigest your favorite character—eat her alive from the inside out. It's the perfect setting for a lingering disability and a slow, painful recovery.
Hollow Organs
Large and small intestines: Both are hollow organs, or transport tubes, for your Chateaubriand for two. The differences between the colon (large intestine) and the small intestine are their size, location and contents. Foul feces is stored in the colon, the last station along a tortuous digestive system. If accidentally ripped open, the colon will leak feces into the sterile abdominal cavity and produce peritonitis.
In the trauma room, the doctor makes the diagnosis with peritoneal lavage: He places a plastic catheter in the belly, runs in saline and out comes saline and usually something ominous. If the fluid retrieved suggests feces, the victim goes immediately to the operating room for bowel repair and a colostomy.
The small intestine contains partially digested food products as well as bile and digestive juices from the pancreas upstream. A small intestine tear, much more subtle, can easily be missed. If not treated, a leaking gut causes peritonitis and big-league infection. Also, both colon and small bowel have supporting tissue called the mesentery that carries the blood supply. Major or minor hemorrhage may result when the mesentery and its blood vessels are severely torn.
Inappropriately worn seat belts can cause intestinal rupture by trapping a loop of intestine internally, causing the pressure in the loop to rise abruptly and burst the wall. Blunt abdominal trauma is anything but benign.
