Bruno José da Costa Medeiros1, Ricardo Silva de Morais2 1 Member of Surgery Institute of Amazonas State - ICEA, Brasilian Society of Trauma Integrated Attendance - SBAIT, Amazonas, Brazil 2 Member of Surgery Institute of Amazonas State - ICEA, Member of Brasilian College of Surgeon - CBC, Rio de Janeiro, Brazil
Date of Web Publication
Correspondence Address: Bruno José da Costa Medeiros Member of Surgery Institute of Amazonas State - ICEA, Brasilian Society of Trauma Integrated Attendance - SBAIT, Amazonas Brazil
Source of Support: None, Conflict of Interest: None
A 50-year-old male come to the hospital victim of damage with a knife to anterior chest (precordial region) after a fight 1 h before. Cardiac tamponade was discovered by focused assessment sonography for trauma and was positive with fluid in pericardial sac. The patient was taken to the operating room. A left anterior thoracotomy was performed. There were three cardiac lesions: One was on the right ventricle, another was very near the left coronary artery (descending anterior branch), and the last one was on pulmonary artery trunk. All the three lesions were corrected with horizontal sutures with prolene 3-0, the lesion near the coronary artery was corrected with a horizontal suture under the artery. Complex cardiac wound is always a challenger to the surgeon, in this case, a cardiac lesion was so near the left coronary artery, a suture over the artery could lead to a myocardial infarction and even death of the patient.
Keywords:Cardiac wound, complex wound, stab wound
How to cite this article: da Costa Medeiros BJ, de Morais RS. Complex cardiac stab wound. J Cardiothorac Trauma 2017;2:17-20
Certainly, there is not any more feared lesion in the popular belief than cardiac lesion. Over many centuries wounds of heart were considered fatal. The heart was considered by the surgery fraternity the “no go” area of the body. Theodore Billroth, Professor of Surgery in Vienna wrote in 1883: “the surgeon who would attempt to suture a wound of the heart should lose the respect of his colleagues”. Cappelen, in 1895, was the first person to suture the heart; the patient died <3 days later. Rehn in 1897, presented the first well-done case of Cardiorraphy in Frankfurt, Germany. He repaired a stab wound of the right ventricle, in a 22-year-old man who had been stabbed in the left fourth interspace and rapidly developed a left hemothorax and was admitted “in extremis”.
Survival rates of cardiac lesion can vary from 20% to 81%. The cardiac injuries can be classified as simple and complex, the simple is small, accessible, and most often a stab wound. The complex is multiple, inaccessible, large, or involve the coronary artery, with very high mortality rates.
In this report, we present a case of complex cardiac injury.
A 50-year-old male was admitted to the hospital, a victim of an injury with a knife to his anterior chest (precordial region) after a fight 1 h before. On arrival, the patient was confused, eupneic, acyanotic, no tachycardia, and presented enlarged jugular veins [Figure 1]. On chest auscultation, he had normal breath sounds and hypophonetic cardiac sounds. Chest inspection showed three stab wounds of 2 or 3 cm each one in cardiac box [Figure 2]. Cardiac rate: 88/min, respiratory rate: 18/min, blood pressure: 120 × 90 mmHg, chest X-ray done in the emergency room was normal, focused assessment sonography for trauma (FAST) positive with fluid on pericardial sac [Figure 3]. The physiologic index of the patient was five stable. The patient went to the operating room. Seconds before the beginning of anesthesia a pericardiocentesis was done according to ATLS protocol and 40 ml of blood was removed [Figure 4] (ATLS, 2014). A left anterior thoracotomy was then performed. A pericardial sac full of blood was noted [Figure 5]. The pericardial sac was opened longitudinal parallel to the phrenic nerve and lots of clots were evacuated. Each stab wound on the chest corresponded to a wound on myocardium. One was on right ventricle, another was very close to the left coronary artery (descending anterior branch) and the last one was on pulmonary artery trunk [Figure 6]. All the three lesions were repaired with horizontal sutures with prolene 3-0, the lesion near the coronary artery was repaired with a horizontal suture under the artery [Video 1] and [Figure 7]. Before the closure of the thorax, a chest tube was placed on pleural space superiorly and posteriorly and the pericardial sac was left open. The patient remained hemodynamically stable during the whole surgery. Chest tube was removed on the 5th day, cardiac enzymes studies measured normal levels and patient was released home with cardiology and trauma surgery follow-up [Figure 8].
In Manaus, Amazonas-Brazil is very common cardiac lesion by knife. In 2012, Costa et al. studied 102 patients with cardiac lesions, 82% of these were victims of stab wound, what characterize a regional peculiarity.
The clinical presentation of penetrating cardiac injuries is related to factors including the wounding mechanism, the length of time elapsed before arrival at a trauma center; the extent of the injury.
Pericardial tamponade can have both deleterious and protective effects. Its deleterious effects can lead to a rapid rise in pericardial pressure and cardiopulmonary arrest, whereas its protective effect will limit extrapericardial hemorrhage into the left hemithoracic cavity preventing exsanguinating hemorrhage.
It is estimated that Beck's Triad is only present in approximately 10% of patients, in this case, the distension of jugular veins and the hypophonetic cardiac sounds were found.
Cardiac Complex stab wounds are difficult to manage, in this case the lesion was classified according to the American Association for the Surgery of Trauma (AAST) as lesion Grade V (AAST, 2016). It was very important to perform an adequate suture, horizontal, and in the case of the lesion near the coronary artery, horizontal suture under running the artery to avoid an abrupt cardiac ischemia. Patient with a small cardiac wound on the right side tends to bleed a little and stop bleeding. If only a small amount of blood leak to pericardial sac, the patient may remain well. In this case, the patient presented with initial signs of cardiac tamponade (Jugular veins distension) because he had three small lesions that together bled a considerable amount of blood needed to initiate a cardiac tamponade.
A pericardiocentesis was done before opening the chest to release the tamponade and to avoid instability during the initiation of anesthesia.
All patients with stab wound on “Cardiac box” or Ziedler area must have a FAST examination or subxiphoid pericardial window if ultrasound facilities are not available to search for and treat early cardiac tamponade, for optimal results (Westphal, 2000).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors thank Dr. Rao Ivatury for English composition advice.
Costa CA, Biroli D, Araújo AO, Chaves AR, Cabral PHO, Lages RO, Padilha TL. Estudo retrospectivo de ferimentos cardíacos ocorridos em Manaus/AM. Rev Col Bras Cir. [periódico na Internet] 2012;39. Disponível em URL: http://www.scielo.br/rcbc. [Last accessed on 2017 Jul 06].