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Home > Case Presentation

A patient was transferred to the Emergency Department of our hospital, having sustained two major stab injuries, about half an hour previously. One of the injuries was located in the epigastric area and the other one was evident just lateral to the xiphoid process and medial to the mid-clavicular line, at the level of the sixth intercostal space. Jets of blood were oozing from both lacerations and direct pressure was applied to control haemorrhage. The patient's breathing was compromised (SpO2 88%), he was in apparent hemodynamic shock (BP=85/55, pulses=140/min) and he was agitated (GCS=13/15). Two large-bore venous catheters were put in place and 2 liters of Ringer's lacted solution were administered immediately. The patient had also suffered two other stab injuries to his left forearm, causing major arterial lacerations; for the control of blood loss from these areas direct pressure was again immediately applied.

The victim was rushed to the operation room immediately upon presentation, where he was intubated and two units of uncrossed packed red blood cells administered. A thoracotomy tube that was put in place did not reveal hemothorax or pneumothorax.

Urgent laparotomy did not reveal abdominal hemorrhage or visceral trauma. The operating team proceeded to urgent left thoracotomy, in order to gain access to the mediastinum. This manoeuvre revealed a large (>6cm) laceration of the left cardiac wall, through which, the internal anatomical landmarks of the left cardiac cavities were clearly visible.

This cardiac laceration caused exsanguination and the patient died fifteen minutes after intubation in the OR.

Incidental findings of a previous thoracic operation were evident by means of fibrous tissue that had developed around the pericardium.

The survival of the patient for so long having sustained this serious injury was attributed to a tamponade effect of the major cardiac laceration by the aforementioned fibrous tissue.

Comments

On 08/25/2010, Dr Chughtai commented:

great management

Just one question sir ! if u were suspecting peneterating cardiac injury , why didnt u do thoracotomy first
instead of laprotomy…......!

On 08/27/2010, ath.pantelis commented:

@ Dr. Chughtai

Thank you for your kind comments.  The fact that tube thoracostomy did not reveal any blood, momentarily drove us away from the thorax and urged us to focus on the abdomen as a possible source of shock in this patient.  The time consumed to access the abdominal cavity and search for a possible source of major blood loss was less than a minute.

On 03/22/2012, tun4343 commented:

22/3/2012, Dr.Natthapong (from Thailand)
Could I ask you one question,if you performed FAST to examine Pericardial fluid.Was it change your management in which cavity be entered first?
Thank you very much

On 04/02/2012, pferrada commented:

To : Dr.Natthapong
When evaluating the pericardium after a penetrating injury it is important to keep in mind if the defect is large enough in the pericardium the blood will be decompressed into the thorax. This is more common in blunt ventricular rupture than in just a simple stab- learned this the hard way…A positive study will help guide therapy a negative study does not exclude injuries.

On 05/29/2015, Saul Torres Flores commented:

Cardiac trauma usually presents different clinical events, but in general, hypoxia, hypercapnia and acidosis are situations which endanger life in a short period of time, that is why it was given a right evaluation, prioritizing the initial management. This injury should have turned out almost in immediate death by its important magnitude; However, as it happens, the patient had a prior injury with fibrous tissue which acted as a support to decrease blood loss.

On 05/29/2015, Saul Torres Flores commented:

A moderate cardiac tamponade may temporarily stop the bleeding of the wounded heart with relatively small risk of cardiac arrest, this is shown in patients with stable injuries with cardiac tamponade, because this is associated with a high rate of survival as opposed to those without tamponade…

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