Bedside ultrasound diagnosis of intracardiac paperclip.

Penetrating cardiac injuries are rarely reported in the literature. Foreign bodies are rarely seen in the heart and most patients with penetrating cardiac injuries die from hemorragic or pericardial tamponade before arriving at the hospital. Bedside ultrasonography is a highly valuable and readily learned tool that has expanded rapidly since its introduction more than 20 years ago. Our case was a 23-year-old convict brought to the emergency department (ED) with a history of continuous chest pain in the upper area of the left side of the chest for one week. Focused Cardiac Sonography (FOCUS) which was performed by emergency physician showed a strong echogenic linear structure with comet tail artifact, free floating in the mid-segment of the left ventricule. Exact localizations of the paperclips within the chest was obtained with multidetector computed tomography and one of them was seen in the left ventricular cavity. FOCUS plays a crucial role in these patients by diagnosing the injury and detecting the complications in emergency department.

INTRODUCTION

Penetrating cardiac injury is a highly lethal trauma. This type of injuries are rarely reported in the literature. Foreign bodies are rarely seen in the heart. The symptoms due to a foreign body in the heart can present from hours to years.[1] These foreign bodies can be asymptomatic even after several years.[2] Most of the cases were accidental or self-inflicted due to an underlying psychiatric illness.[3] Here, we present a patient who had intracardiac foreign body diagnosed by emergency physician with bedside ultrasound.

CASE REPORT

A 23-year-old convict was brought to the emergency department (ED) with a history of continuous chest pain in the upper area of the left side of the chest for one week. His history revealed that self-injurious behavior while in jail. He denied any illicit drug use. The patient appeared well and his vital signs were stable. Physical examintaion has revealed normal findings except the presence of eight puncture sites on the skin to left of the middle sternal border [Figure 1]. Further questionining revealed the reason of these injuries and he accepted having inflicted his present injury on himself by paperclips.

Figure 1

The puncture sites on the patient's skin to left of the middle sternal border

Electrocardiography was normal and Focused cardiac sonography (FOCUS) was performed by emergency physician using an M7R® model ultrasound machine with a 3.6-MHz microconvex transducer (Mindray Bio-medical Electronics Co., Shenzhen, China) and ultrasonographic views were recorded. FOCUS have showed no pericardial effusion, normal regional and global left ventricular function, and a strong echogenic linear structure with comet tail artifact, free floating in the midsegment of the left ventricule [Figure 2]. A routine chest X-ray showed seven paperclips within the chest, six of them superimposed on the cardiac silhoutte [Figure 3]. Exact localizations of the paperclips within the chest were obtained with multidetector computed tomography and one of them was seen in the left ventricular cavity [Figure 4]. Cardiovascular surgeons recommended an operational removal of the paperclip to the patient and he refused the operation. He is anticoagulated and discharged from hospital with a follow-up plan.

Figure 2

The ultrasonographic image of patient's heart. White arrow shows the echogenic linear structure with comet tail artifact in the mid-segment of the left ventricule

Figure 3

Chest X-ray of the patient showing seven paperclips within the chest, six of them superimposed on the cardiac silhoutte

Figure 4

Exact localizations of the paperclips within the chest was obtained with multidetector computed tomography. Multiple paperclips seen in chest cavity (Figure 4a, white arrow) and one of them was seen in the left ventricular cavity (Figure 4b, white arrow)

DISCUSSION

Bedside ultrasonography is a highly valuable and readily learned tool that has expanded rapidly since its introduction more than 20 years ago. Nowadays, it has lent itself to the evaluation and management of most patients through the incorporation of multiple ultrasound examinations within a single patient encounter.[456] The information gained can provide crucial information at the bedside, which can enhance diagnostic certainty and guide management.

Foreign bodies are rarely seen in the heart and most patients with penetrating cardiac injuries die from hemorragic or pericardial tamponade before arriving at the hospital. Sewing needles, bullets, pellets, misseles, and pencils have been reported as foreign bodies penetrating the heart.[78] Most of the cases were accidental or self-inflicted due to an underlying psychiatric illness.[3] Multiple puncture sides in a patient with a history of antisocial personality may suggest the possibilty of self injury. Bedside ultrasonography is a valuable tool for emergency physician (EP) for early diagnosis of both foreign body and also early complications such as cardiac tamponade. A further potential complication is thrombus formation around the needle or in the chambers of the heart which may embolise distally.[9] Since our patient refused the operational removal of the foreign body, we have decided to give prophylactic anticoagulation and antibiotic therapy.[1] Radiologic demostration of the foreign body is important to guide surgical treatment. Altough the chest radiograph confirms the nature of the injury, exact compartmental location should be assesed by computed tomography.

FOCUS plays a crucial role in these patients by diagnosing the injury, detecting the complications such as tamponade and also possible thrombus formation around the foreign body or in the cavities of the heart.