Early Diagnosis of Penetrating Cardiac and Pleural Injury by Extended Focused Assessment with Sonography for Trauma.

In India, stab injury is not uncommon, but identifying potential life threatening conditions in the emergency room (ER) and initiating prompt treatment are challenging. This is a case report of a young patient who presented to the ER with assault injury to the chest and shock; timely extended focused assessment with sonography for trauma helped to fast-track the patient to the operating room. A brief review of diagnosis and management of penetrating cardiac injury is presented herewith.

INTRODUCTION

The reported incidence of penetrating cardiac injuries varies among regions. The number of these injuries in a given center depends on local trends in urban violence and the quality of prehospital care. In approximately 80% of patients who reach the hospital alive, blood will accumulate in the pericardium with symptoms of tamponade.

Emergency interventions, rapid patient transportation, quick assessment, and immediate operation are lifesaving measures in cardiac trauma cases. The most important tool in the rapid evaluation of cardiac trauma in the Emergency Department (ED) is bedside sonography and echocardiography.[12] With this in the background, we report a case of a young man who presented with penetrating cardiac trauma with cardiac tamponade and hemothorax.

CASE REPORT

A 23-year-old man presented to the ED 2 hours after a stab injury to the left side of the chest. He complained of breathing difficulty and dizziness. On arrival, he was conscious, Heart rate 120/min, blood pressure 70/40 mmHg, SPO 96% room air. He was triaged with emergency severity index (ESI) level 1. Local examination revealed 2 cm × 1 cm muscle deep laceration in the left third intercostal space anteriorly [Figure 1]. At resuscitation, heart sounds were muffled on auscultation, jugular venous pressure was 8 cm's above the sternal angle, and breath sounds were diminished on the left lung base. Along with the resuscitative measures, extended focused assessment with sonography for trauma (eFAST) was performed and revealed pericardial effusion [Figure 2]. Screening echocardiography revealed global pericardial effusion with tamponade.

Figure 1

2 cm × 1 cm muscle deep laceration in the left third intercostal space

Figure 2

Circumferential pericardial effusion on focused assessment with sonography for trauma

Urgent cardiothoracic consultation was obtained and the patient was posted for emergency exploratory median sternotomy. There was a pericardial injury 1 cm × 1 cm over the left lateral aspect in the left ventricle, and about 500 mL of blood with clot was removed. There was a rent in the interventricular region below the left anterior descending coronary artery and D1 junction involving the epicardium measuring 1 cm × 0.5 cm, which was repaired. Further, about 1200 mL of blood with clots was let out from the left pleural cavity. Left pleural and pericardial drains were inserted. The patient was managed in the cardiothoracic Intensive Care Unit postoperatively. The postoperative period was uneventful, and he was discharged at 7th day with a good left ventricular function.

DISCUSSION

About 59% of penetrating cardiac injuries are stab wounds, 26% gunshot wounds, and 15% others; 80% of patients die before they reach a hospital.[3] In another report from Kurdistan, the mechanism of injury was mostly penetrating (85.71%), among which stab was the most causative agent (57.14%) and the most common affected site was the fourth intercostal space (28.57%).[4] Right ventricular injury is most frequent (46%), followed by injuries to the left ventricle and right atrium (30% and 11%).[3] Most victims die at the scene or in the emergency room.[5] Most patients present with profound hypotension and require immediate surgical intervention, yet others may present without overt symptoms and signs of significant heart injury.[6] Thus, the diagnosis of cardiac injury in the latter group of patients should be made promptly to avoid delay in treatment and preventable deaths.

The initial evaluation of a trauma patient sustaining penetrating chest trauma includes physical examination and chest radiography. The sensitivity and specificity of both examinations for diagnosing cardiac injury are relatively low.[7] In recent years, FAST examination has become an integral part of the primary survey and is found to be highly valuable in the diagnosis of pericardial effusion (sensitivity, 92–100%; specificity, 99–100%), which is very commonly associated with penetrating cardiac injuries.[89] Overall, survival is better than 80% in patients who arrive at hospital with signs of life, early diagnosis, and management.[10]

CONCLUSION

The prompt management of penetrating cardiac injuries is dependent on rapid diagnosis, resuscitation, and emergency surgical repair. eFAST is an easy and noninvasive imaging modality which can help the emergency physician to decrease the time needed to establish a diagnosis of penetrating cardiac injury and is very useful to detect fluid in pleural space as well.

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Conflicts of interest

There are no conflicts of interest.