|Year : 2017 | Volume
| Issue : 2 | Page : 41-43
Penetrating chest injury involving pulmonary artery: Challenges at emergency department
Joseph Alexis1, Vinay R Pandit1, Nanda Kishore Maroju2, Jency Antony3
1 Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||26-Apr-2018|
Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
A case of penetrating chest trauma due to stab injury is described. At presentation to the emergency department (ED), he was hemodynamically unstable and only a small sutured left parasternal wound was noted. Extended focused assessment sonography in trauma revealed pericardial tamponade and left-sided hemothorax. He was shifted to the operating room immediately and rent in the anterior wall of the main pulmonary artery was closed. Timely diagnosis and the management strategy in ED resulted in successful outcome.
Keywords: Emergency department, management, penetrating chest trauma
|How to cite this article:|
Alexis J, Pandit VR, Maroju NK, Antony J. Penetrating chest injury involving pulmonary artery: Challenges at emergency department. Niger J Cardiovasc Thorac Surg 2017;2:41-3
|How to cite this URL:|
Alexis J, Pandit VR, Maroju NK, Antony J. Penetrating chest injury involving pulmonary artery: Challenges at emergency department. Niger J Cardiovasc Thorac Surg [serial online] 2017 [cited 2020 Dec 5];2:41-3. Available from: http://www.nigjourcvtsurg.org/text.asp?2017/2/2/41/231277
| Introduction|| |
Chest trauma accounts for 10% of global admissions for trauma. Penetrating chest trauma is mostly due to violence and has a higher mortality than blunt trauma ranges from 15% to 77%. Injury to the mediastinal great vessels is the most lethal complication of penetrating chest injuries. A single stab injury in the thoracic region can cause extensive to the great vessels and has high fatality rates. The clinical presentation of penetrating chest trauma can be varied, and decision-making requires careful consideration of the risk-benefit ratio in individual cases. Early recognition, better resuscitative measures, and effective intervention can significantly alter their outcomes. This report documents the case of a patient who presented to us with a history of a stab wound to the chest.
| Case Report|| |
A 30-year-old male patient presented to emergency department (ED) 6 h following a knife assault with penetrating injury to his chest. On admission, the patient was conscious and alert but appeared to be breathless. On examination, he had a pulse rate of 122/min, blood pressure of 70/50 mmHg, respiratory rate of 45/min, and SpO2 of 94%. He had distended neck veins, decreased breath sounds on the left side of the chest, and muffled heart sounds, suggestive of classical Beck's triad. The only external injury observed was a sutured wound over the left upper parasternal region, measuring around 3 cm in length as shown in [Figure 1]. The patient was resuscitated as per ATLS guidelines with oxygen and small fluid bolus. Extended focus assessment sonography in trauma (e-FAST) was done by the emergency physician revealed evidence of pericardial tamponade, distended inferior vena cava and left side hemothorax as shown in [Figure 2]. Chest X-ray demonstrated left massive hemothorax with the tracheal shift to the right as shown in [Figure 3]. In view of the patient's clinical presentation, the patient was transferred to the operating room for emergency surgery. The emergency team decided not to perform pericardiocentesis and tube thoracostomy, as these procedures might delay the definitive treatment. A median sternotomy was performed, and a 1 cm - sized rent was identified over the anterior wall of main pulmonary artery at the junction of the right ventricular outflow tract. In addition, about 800 mL of clotted blood in the pericardial cavity and about 1200 mL of blood in the left pleural cavity was evacuated. The vascular defect was repaired with 4-0 polypropylene pledgeted purse string sutures. The patient had an uneventful postoperative recovery and was discharged on the 6th postoperative day.
|Figure 1: A small left parasternal sutured wound which happened due to stab injury.|
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|Figure 2: Extended focus assessment sonography in trauma showing pericardial tamponade.|
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|Figure 3: Chest X-ray demonstrated left massive hemothorax with tracheal shift to the right.|
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| Discussion|| |
All patients with penetrating wounds of the chest and upper abdomen are at risk of life-threatening intrathoracic and mediastinal injuries. Penetrating chest trauma is mostly secondary to violent acts. In our geographical area, stabbing is common, as opposed to gunshot injuries as in the West. The majority of victims are generally males.
A high index of suspicion of cardiac injury is required for hemodynamically unstable patients with penetrating thoracic wounds, especially if the injury involves the left or anterior chest wall. In a meta-analysis, Rhee et al. revealed that overall survival rates were 17% after stab wounds and 4% after gunshot wounds. In 92% of such patients having a good neurological recovery if they survived their hospitalization. The risk factors for dismal prognosis are cardiac injury, left-sided thoracotomy, unstable hemodynamics at initial presentation, male gender, junior personnel receiving and managing ED cases, and presentation very late at night or early in the morning.
Complete penetration of the chest wall by a pocket knife can be easily achieved. Ultrasonogram and echocardiogram are the investigations of choice for screening of cardiac tamponade and hemopneumothorax in trauma patients. The sensitivity of ultrasonogram in detecting hemopericardium is about 86.7%, with a positive predictive value of 77%. Advanced trauma life support course with e-FAST is the standard of care in the initial assessment and evaluation of trauma patients. The role of rapid infusion of intravenous fluids is questionable in the resuscitation of trauma patients presenting with hypotension. In comparison to delayed or limited fluid resuscitation, early aggressive fluid resuscitation of adults with penetrating torso trauma appears to be detrimental to patient outcomes. However, there is insufficient evidence to recommend either small aliquots of fluid titrated to clinical response or withholding all fluid resuscitation until operative management. Current guidelines support the judicious use of fluids in such patients.
Conventionally, chest tube thoracostomy is the primary modality for managing nonmediastinal peripheral chest injuries. Cardiac tamponade is life-threatening condition that requires urgent pericardiocentesis. It is a life saving procedure also carries a high risk of complications. In this regard, imaging support and the careful planning of the proper entry site are fundamental for a safe and successful procedure. Nowadays, echo-guided procedures demonstrated a greater success rate and a minor complication rate and has provided the best anatomical approach among the apical, subcostal, and parasternal approaches. The optimal entry site as the point where the pericardial space is closest to the probe, and the fluid accumulation is maximal, with no intervening vital organs. The effect of pericardiocentesis is often immediate. The withdrawal of even a small amount of pericardial fluid may dramatically improve the patient's hemodynamic status.
The pericardial window can also use for drainage of accumulated pericardial fluid. Pericardial window involves the excision of a portion of the pericardium, which allows the effusion to drain continuously into the peritoneum or chest. It is mainly indicated in symptomatic pericardial effusions, delayed hemopericardium, or effusions after cardiac surgery.
In hemodynamically unstable patient, there is no absolute contraindications exist to performing pericardiocentesis. Some authors argue that traumatic cardiac tamponade should be treated by emergent thoracotomy. There is no significant difference in overall mortality between open surgical drainage and percutaneous pericardiocentesis for symptomatic pericardial effusions. There may be more procedural complications following surgical drainage of a pericardial effusion. Repeated procedures may be needed if the effusion is drained using pericardiocentesis.
In this case, emergency thoracostomy and pericardiocentesis were avoided as the managing team suspected a major vascular injury. In the presence of major vascular injuries, a drainage procedure has the potential to aggravate ongoing mediastinal bleeding due to sudden decompression. Emergency thoracotomy performed in the operating room with ongoing resuscitation may have a more favorable outcome in hemodynamically unstable patients. We decided against emergency room thoracotomy as evidence suggests that its outcomes are uniformly poor.
This case had rent in the main pulmonary artery without any associated lung parenchymal injury, which is rarely reported. Deneuville described seven cases of penetrating chest trauma involving pulmonary artery and its branches. He reported that isolated pulmonary artery injury carries a good prognosis as these are surgically amenable. Mortality will be high if there is concurrent other vascular and pulmonary injury which might require pneumonectomy. The interval between the injury, hospitalization and surgery influences the outcome. Even though this case presented 6 h after the injury; isolated pulmonary artery lesion, early diagnosis and management decision in ED resulted in the favorable outcome.
| Conclusion|| |
Hemodynamically unstable patients following a penetrating injury to the anterior chest wall are likely to have a mediastinal great vessel and cardiac injuries. A high index of suspicion for major vascular injury, along with prompt e-FAST and echocardiogram in the ED may aid in reliable decisions. Isolated pulmonary artery injury will carry a good prognosis. Early thoracotomy in the operating room may be the best option in cases suspected to have major vascular or cardiac injuries.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]