The Successful Management of A Penetrating Cardiac Injury in A Regional Hospital: A Case Report
The Successful Management of A Penetrating Cardiac Injury in A Regional Hospital: A Case Report
The Successful Management of A Penetrating Cardiac Injury in A Regional Hospital: A Case Report
4, 2008
Stabbing injuries of the heart are uncommon but have a high mortality rate. Most patients with
cardiothoracic stabbing injuries die on admission to the emergency department. The management of
cardiac stabbing injuries is dependent on rapid diagnosis and prompt surgical repair. We report our
successful management of a patient with left ventricle penetrating injury. A 36-year-old female suffered
from a stabbing injury to the left chest with hypovolemic shock. She underwent emergency anterolateral
thoracotomy with repair of left ventricle without cardiopulmonary bypass. The postoperative course was
uneventful except for acute tubular necrosis and the patient recovered gradually over the next two weeks.
The patient was discharged on the 17th days after the operation without any follow-up problems.
sence of the knife in the left chest, active bleeding pericardium. Next, a 16-French Foleys urine
via the left chest was occurring. Her heart rate and catheter was inserted and the balloon was filled
respiratory rate were measured as 119 per minute with saline to obstruct the penetrating wound of the
and 25 per minute, respectively. Her blood pressure LV by gentle traction (Fig. 1). Direct LV repair was
was undetectable and her jugular veins were made using 3 O prolene with five interrupt stitches
distended. We performed endotracheal intubation that were reinforced with a plaget (Fig. 2). The lac-
immediately and cardiopulmonary resuscitation. eration wound of the left upper lobe of lung was
An electrocardiogram showed tachycardia and ST repaired with 3 O catgut. During the operation, we
segment elevation in V3-V5. An arterial blood gas did not use a cardiopulmonary bypass to facilitate
test showed metabolic acidosis (pH: 7.004, HCO3: the cardiac repair.
10.8, BE: -20.2). An echocardiogram resulted in Postoperatively, acute tubular necrosis was
suspected pericardial effusion. She was transferred to noted and was treated with hydration and a low
the operating room after a short period of hemodynamic dose diuretic agent, which resulted in recovery.
improvement. An anterolateral thoracotomy via the Elevated serum levels of amylase and lipase (amy-
fourth intercostal space was made at once. lase: 222 U/L, lipase: 175 U/L) were also noted,
On exploration, a laceration wound over but they returned to normal spontaneously several
the left upper lobe of lung about 1 cm in length days later. An echocardiogram was performed on
with active bleeding and an air leak were noted. the sixth day after the operation and showed normal
Pericardial tamponade was also noted and we open LV and right ventricle (RV) wall motion as well
the pericardium. A penetrating wound of the left as adequate LV systolic function. The patient was
ventricle (LV) about 1 cm in length was found. discharged on the 17th day after the injury with
A large amount of blood was evacuated from the fully mobility and without complications.
proximately half of all cases but are non-specific(1). bypass is needed. This incision also causes less
EKG findings can include low voltages, S-T postoperative pain and respiratory dysfunction than
changes or inverted T waves. The most important a thoracotomy. However, it gives poor access to the
tool in the rapid evaluation of cardiac injury is back of the heart. A left anterolateral thoracotomy
echocardiography. It can detect the pericardial is the incision of choice for the management of
effusions and suggest, if the results are positive, patients with penetrating cardiac injuries that ar-
that the surgeon has the option of performing a rive in extremis(6). This incision is most often used
thoracotomy, depending on the hemodynamic in the emergency department for resuscitative pur-
stability of the patient. Echocardiography can poses. It is also the incision of choice in patients
decrease the time needed to establish a diagnosis undergoing celiotomy who deteriorate secondary to
and thus it increases the survival rate. Furthermore, unsuspected cardiac injuries. The left anterolateral
it also is useful in diagnosing abnormal pericardial thoracotomy can be extended across the sternum as
fluid in doubtful cases(5). a bilateral anterolateral thoracotomy if the patients
Pericardiocentesis was not suggested be- injuries extend into the right hemithoracic cavity(7).
cause penetrating into a cardiac chamber may This approach is the incision of choice in a patient
yield a false-positive result, while clotting of who is hemodynamically unstable or suffering from
the blood in the pericardial cavity may yield a injuries that have traversed the mediastinum. This
false-negative result. Furthermore, drainage of incision allows full exposure of the anterior medias-
the pericardial blood is often incomplete and tinum and both hemithoracic cavities.
tamponade may persistent or recur. Nonetheless, A f t e r t h o r a c o t o m y o r s t e r n o t o m y, t h e
pericardiocentesis may have a role when no surgeon pericardium should be opened and the heart should
or operating room is available because the proce- be made visible. This should relieve tamponade, if
dure can be carried out in the emergency room and present and allows digital control of the ventricle
pericardial decompression by pericardiocentesis wound. If the injury is quite large, a urinary cath-
might create the time to allow transfer of the eter can be inserted through the defect and the
patient to an operating room or trauma center. balloon filled with enough fluid to control most of
Pericardiocentesis was not performed in our case the bleeding. However, if the balloon is overfilled,
after pericardial tamponade was clearly impressed the chamber volume and cardiac output may be
via echocardiography. We immediate perform a compromised. In atrial and caval injuries, a side-
thoracotomy to control bleeding and repair the heart biting vascular clamp can be used to control
injury. bleeding during repair. It is very important that
In contrast to abdominal injuries, which can direct repair of ventricle wounds is not carried
be easily accessed via celiotomy, the management out. Ventricular wounds are best sutured with
of penetrating cardiothoracic injuries requires ac- interrupted pledgeted mattres. Fortunately, there
curate judgment when selecting the best approach were no coronary artery, valve or large vessel
to the injury. A median sternotomy is the incision injuries in our case. After opening the pericar-
of choice in patients admitted with penetrating dium, a urinary catheter was inserted via the LV
cardiac wounds that may harbor an occult or non- penetrating wound and fill with adequate fluid.
hemodynamically compromising cardiac inju- The patients vital signs began to improve after the
ries(6). This provides better exposure to all parts of bleeding was controlled and we were able to repair
the heart and is convenient if a cardiopulmonary the heart without any problems.
164 J Emerg Crit Care Med. Vol. 19, No. 4, 2008
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Wounded during the 1992-1994 war in Bosnia MK, Lovoulos C. Cardiopulmonary bypass for
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Rossouw GJ. Delayed pericardial effusion fol- 9. Tesinsky L, Pirka J, Al-Hiti H, Malek I. Case
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Penetrating left ventricular stab wound: a meth- 3.
166 J Emerg Crit Care Med. Vol. 19, No. 4, 2008
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