What Is Impalement Injury

  • Saba Amber BSc, Manchester Metropolitan University, UK

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Introduction to impalement injury 

An impalement injury involves an object that has punctured an area of the body and is still present. This can range from something as small as a nail from a nail gun to a large piece of metal from a car accident. More severe impalement injuries are not very common in day-to-day life but can prove to be very dangerous and even fatal if not treated correctly and swiftly. 

Mechanism of impalement 

There are different ways for an impalement injury to occur. This may include something like a freak accident while doing some DIY work- a nail or similar item could impale an extremity such as the hand or foot. Alternatively, an individual may be impaled by a vertical item (such as a metal pole) after a fall from some height. Another example could be a hunting accident where an individual may be impaled by an arrow from a crossbow. Additionally, impalement injuries are more common in severe car accidents. Stab wounds can also be considered to be an impalement injury.

Types of impalement injuries 

The location of the impalement injury can determine the severity of the impalement injury and whether it is internal or external. Impalement injuries to the extremities like the hand or foot are less likely to be fatal on their own but the untimely removal of the impaled object can still cause the individual to bleed out or lead to infection.

An impalement injury in the torso area is a lot more dangerous as this area contains most of your organs and major blood vessels. Any damage to this area can prove to be fatal. Extreme care should be taken to not disturb the impaled object when administering first aid and instead, the impaled object should only be removed at the hospital.1 There is the risk of puncturing a lung or the removal of an impaled object can lead to haemorrhaging (extreme loss of blood through a damaged blood vessel).2

Take particular care if the impaled object is in the eye. Do not put pressure on the eye area and instead cover both eyes, if possible, as leaving one eye uncovered may lead to involuntary movement in the eye with the impaled object. This can lead to further damage, so it is best to provide reassurance to the individual (as it may cause them distress if they are unable to see what is happening) but ensure that both eyes are covered. 

There have been case studies of impalement injuries to the brain or skull which have documented cases of a full recovery. However, this is a particularly dangerous and difficult injury to treat as the risk of complications is very high (neurological damage- to the brain and its functions).3 Care must be taken to avoid moving the individual and waiting for a professional before transporting the individual to the hospital (where possible).  

Causes and risk factors

Impalement injuries are relatively uncommon. Certain activities can increase your chances of suffering an impalement injury such as unsafe practices in areas like building sites or not following proper safety protocols. Improper handling or storing of sharp objects may also increase the chances of an impalement injury. It is a good idea to follow a guide or some training when handling new equipment for the first time. 

Injury assessment and diagnosis 

Prompt medical attention can increase the chances of survival and allow you to make a full recovery. It may be necessary to carry out a scan (x-ray or CT scan) when you reach the hospital to confirm the trajectory of the impaled object and to decide upon the best possible method for removing the impaled object.4 However, this may not always be necessary or there may not always be time for such scans if the impalement injury is particularly severe or in cases where movement is exacerbating the injury. In these cases, it is better to directly remove the object and carry out the scans afterward. 

Immediate first aid and prehospital care 

It is extremely important that the impaled object is not removed at the scene unless it is done under the supervision of a medical professional. And even then, it is unlikely that they would remove the entire impaled item. Instead, the first responders would be more likely to cut the individual free if the object is too large making it difficult to transport the patient to the hospital. For example, in cases such as impalement injuries caused by a car accident- the firefighters may need to cut the impaled object to free the patient and allow the paramedics to safely transport the patient to the hospital.

Under no circumstances should you attempt to remove the impaled object yourself. This can lead to the individual bleeding out or may cause further internal damage to the organs depending on how the impaled object is positioned and whether it has straight or jagged sides. Alternatively, you can apply firm pressure to the site of the wound while avoiding any pressure on the impaled object. This can help to slow down the bleeding but by avoiding the impaled object, you can avoid further internal damage. Only attempt this if it is safe to do so and does not move the impaled object. 

It may also be a good idea to secure the object if you need to move the individual so you can call for help (this may be more relevant in cases of accidents that occur in remote areas, and you need to travel for medical assistance).5 If you need to secure the impaled object, take care not to move the object itself and try to securely wrap the surrounding area with a thick supportive material like gauze or rolled towels and tape them into place. This will prevent unnecessary movement of the impaled object while transporting the individual. 

Treatment and management 

In more severe cases of impalement, the object would need to be removed surgically. This can normally be done in a single surgery and follow-up appointments can be made to continue to monitor the healing of the wound. The site of the injury would need to be kept clean and sterile to prevent infection.

As an impalement injury can be quite deep, local anaesthetic may not be completely effective in preventing pain during removal. If the impalement injury results in a particularly deep wound, then packing (strips of dressing placed inside the wound to soak up blood and fluid) may be used during the healing process to prevent infection. 

Potential complications 

Impalement injuries can have different complications depending on the severity of the injury and the circumstances around how it occurred. 

  • The site of the wound may become infected due to improper care.
  • Complications from an infected wound such as sepsis (blood poisoning).
  • There may be internal damage to organs from the initial impalement injury.
  • Possible mental health problems after the injury depending on the long-term implications of the injury or the circumstances surrounding the injury (anxiety or depression).

Recovery and rehabilitation 

Your recovery largely depends on the severity of the injury. Minor impalement injuries to the extremities like the hands and feet may not have a long recovery period and you can return to work or your daily activities without much delay. However, some more serious injuries may take longer to heal, and, in some cases, there may be some lasting damage that can interfere with your return to daily life. In these cases, your healthcare provider may suggest you try physical therapy or some other form of rehabilitation to restore a full range of movement.

Preventing impalement injuries 

It is important to follow the safety instructions given at different locations such as building sites or sites for recreational activities that involve sharp objects. These precautions were put into place for a reason. 

Follow guidelines when using new equipment for the first time and confirm how to use it if you are unsure.  

Legal and ethical considerations 

While it is the responsibility of the employer or owner to carry out risk assessments and put reasonable precautions in place, it is also the responsibility of the individual to take care of and use their judgment.

Public awareness and education 

While it is best to leave the actual medical aid to the professionals in cases of serious injuries, it is important to have some basic first aid skills. Some workplaces offer such courses to their employees but different charities such as the Red Cross or St John’s Ambulance also offer first aid courses. Some local councils also have information about short courses available in your local area.

Summary

Impalement injuries, while uncommon, can range from minor to severe and life-threatening. It is very important to seek prompt medical aid and to avoid any unnecessary movement that could disturb the impaled object. Do not remove the impaled object from the body, instead leave the object to be removed at the hospital. If necessary, you can apply pressure to slow down the flow of blood or if required, you can carefully secure the object to transport the patient to seek medical aid. Swift medical attention can improve the outcome reduce permanent damage and increase the chances of survival. 

References

  • Muhammad Afzal R, Armughan M, Javed MW, Rizvi UA, Naseem S. Thoracic impalement injury: A survivor with large metallic object in-situ. Chinese Journal of Traumatology [Internet]. 2018 Dec 1 [cited 2023 Oct 10];21(6):369–72. Available from: https://www.sciencedirect.com/science/article/pii/S1008127518300786
  • Edwin F, Tettey M, Aniteye L, Kotei D, Tamatey M, Entsuamensah K, et al. Impalement injuries of the chest. Ghana Medical Journal [Internet]. 2010 Jun 8 [cited 2023 Oct 10];43(2). Available from: http://www.ajol.info/index.php/gmj/article/view/55320
  • Koko AM, Lasseini A. Impalement brain injury: report of five consecutive clinical cases. Egyptian Journal of Neurosurgery [Internet]. 2020 Mar 3 [cited 2023 Oct 10];35(1):5. Available from: https://doi.org/10.1186/s41984-020-00077-8
  • Ahn SR, Lee JH, Kim KY, Park CY. Pre-hospital and in-hospital management of an abdominal impalement injury caused by a tree branch. J Trauma Inj [Internet]. 2021 Dec 16 [cited 2023 Oct 10];34(4):288–93. Available from: http://jtraumainj.org/journal/view.php?doi=10.20408/jti.2021.0051
  • Isenburg S, Jackson N, Karmy-Jones R. Removal of an impaled knife under thoracoscopic guidance. Canadian Respiratory Journal [Internet]. 2008 [cited 2023 Oct 10];15(1):39–40. Available from: http://www.hindawi.com/journals/crj/2008/452421/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Saba Amber

Medicinal and Biological Chemistry- BSc, Manchester Metropolitan University

Saba is a recent graduate in Medicinal Biochemistry with a particular interest in pharmacology.

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