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A 17 year old boy got stabbed in the left parasternal area during a fight in his neighbourhood. He collapses in the street and an ambulance paramedic has the expertise to bring him to the closest appropriate emergency hospital while monitoring him and giving him a minimal fluid resuscitation. His systolic BP at arrival is 85mmHg and his neck veins do not appear distended. The FAST assesses his heart and reveals a large pericardic effusion. The surgeon decides to take him to theater ASAP. His total prefospital time was 30min and his time in the ER another 35 min. In the operating theater the surgical team is scrubbing and the patient becomes unconscious as he is put on the table. Without draping nor cleaning, while the anesthetic doctor is intubating the patient an emergency left lateral thoracotomy is performed and the cardiac tamponade released. The surgeons index finger controls the large laceration in the right ventricle. Skin Clips are used to control the laceration in the first place, the fibrillating heart is defibrillated and a running suture with 2 nylon on a large needle is performed on the beating heart. The pericardium is closed partially without a drain and the chest is washed out with 5 liters of sterile water. A single chest drain is placed in the left chest and the thorax closed in two layers. The patient was extubated after 2 hours in the ICU because his lactate levels had cleared from 5.8 to 2.5. He was eating breakfast the next morning and was mobilized out of bed and send to the ward where he is waiting discharge. This swift management highlights the expertise of an entire ED and surgical team that deals with these injuries three times per month on average. The last consecutive four front room thoracotomies all survived and the last 12 patients with a penetrating cardiac wound all left our hospital alive and fully functional after surgical repair. No patient died with an unrecognized intrapericardic wound since 12 month. In 2008's 35 consecutive cases, 29 patients survived (82%). The prompt prehospital transfer with minimal fluid in all shocked precordial wounds with possible cardiac wounds (permissive hypotension) allows more patients to arrive with signs of life. A swift ED team with emergency physicians and a close collaboration with the surgical team gives the best possible outcome in penetrating cardiac injuries.


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