International Journal of Surgery Case Reports 113 (2023) 109064

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Delayed presentation of penetrating cardiac injury successfully managed in

resource limited setting: A case report
Ayenew Gaye Gucho *, David R. Jeffcoach
Department of General Surgery, Soddo Christian Hospital, PO BOX: 305, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Penetrating cardiac injury is rare and historically known to have very poor prog­
Penetrating cardiac injury nosis. Even today, 90 % of patients die before arriving to hospital. Even though patient presentations can be
Median sternotomy atypical, organized timely intervention can lead to survival.
Pericardial window
Case report: A 21 years old arrived 5 h after stab injury to right anterior chest. He was hypotensive with a sucking
wound bleeding on his right chest as well as hemothorax on the same side. Chest tube and pericardial window
were both done with blood in pericardial space. Median sternotomy was done and revealed right atrial perfo­
ration. The perforation was repaired and the patient was discharged and continues to do well on follow up.
Clinical discussion: For most patients, time from injury to surgery is short. Focused and organized surveys as well
as resuscitation are valuable for any patent with penetrating thoracic trauma. With a patient in hemorrhagic
shock and a penetrating wound near the heart, a pericardial window is required regardless of the absence of
pericardial fluid on ultrasound and in this case proved to be lifesaving. If there is a hole in the pericardium
communicating with the pleural space the pericardial blood may decompress into the pleural cavity and not be
visible on ultrasound.
Conclusion: Regardless of its rare prevalence, high index of suspicion for cardiac injury is extremely important in
all patients with penetrating chest trauma in the cardiac box regardless of atypical presentations. With rapid
diagnosis, capable surgeon availability, and availability of blood products, patients can survive this injury.

1. Introduction exceedingly rare due to the observed near 100 % pre-hospital mortality
[11]. Even today, about 90 % of the patients die before reaching the
Penetrating cardiac injury is rare accounting only 0.1 % of most hospital [3].
trauma admissions [1]. Although wounds of the heart had captured the Although limited in Sub- Saharan Africa, recent experience from
imagination of poets and artists for centuries, their treatment continued trauma centers in South Africa focus on structured approach for early
to elude physicians until relatively recently. Historically, heart injuries definitive management and acceptable results [4]. The experience in
had fatal outcomes and were considered untreatable. In the early 18th Ethiopia is limited to few cases in the capital [8]. Here, we present a case
century Boerhaeve labeled all penetrating cardiac trauma as fatal. Bill­ of delayed penetrating cardiac injury successfully manages in a resource
roth stated “The surgeon who should attempt to suture a wound of the limited setting. This work has been reported in line with SCARE criteria
heart should lose the respect of his colleagues” [2]. In 20th century [9].
emergency operative intervention was used as definitive treatment for
cardiac trauma instead of pericardiocentesis. 2. Case description
Common presentation of patients after cardiac injury is with features
of cardiac tamponade or hemorrhagic shock. Additional symptoms of A 21-year-old patient from remote area and low socioeconomic
chest pain and shortness of breath are present due to associated hemo­ background arrived 5 h after he was stabbed to his anterior chest and
thorax or pneumothorax. In hemodynamically unstable patients with neck by a sharp knife. He was involved in a family dispute over a plot of
stab injury in “cardiac box”, the diagnosis can be clinically straightfor­ land. Following the trauma, he had bleeding from the injury sites,
ward. But delayed presentation of penetrating cardiac injuries is shortness of breath and chest pain. He was taken to a local clinic and

* Corresponding author.
E-mail address: ayenewimpact68@gmail.com (A.G. Gucho).

https://doi.org/10.1016/j.ijscr.2023.109064
Received 1 October 2023; Received in revised form 8 November 2023; Accepted 11 November 2023
2210-2612/© 2023 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.G. Gucho and D.R. Jeffcoach International Journal of Surgery Case Reports 113 (2023) 109064

referred immediately with penetrating thoracic trauma.

On arrival to hospital, his blood pressure was 91/61 mmHg, pulse 85
bpm and oxygen saturation of 98 % on oxygen support. Physical ex­
amination showed 1 by 2 cm right side lateral neck (zoneII) superficial
wound with no active bleeding or expanding hematoma. There was 2 by
3 cm open sucking wound with active bleeding on his right chest 4th
intercostal space (Fig. 1). On Auscultation, air entry on right side of his
lung was decreased. Focused abdominal sonography for trauma (FAST)
showed no collection in the abdomen or pericardial space. After starting
resuscitation with crystalloid, chest x ray was done and it showed right
side hemothorax (Fig. 2).
After typing and crossmatch for blood products, the patient was
taken to operation theatre under leadership of a surgeon, prepped chin
to pubis, and then intubated. Right side chest tube was inserted and 500
ml of frank blood was evacuated upon insertion and continued to in­
crease. Subxiphoid pericardial window was done and it was positive for
hemopericardium. Fig. 2. Chest X ray showing hemothorax on right side.
At this point median sternotomy was done. Clotted as well as fresh
blood was found upon opening the pericardium. There was a hole in the
right pericardium and about 1.5 cm long laceration on the right atrium
was found and it was profusely bleeding. There was also a 3 cm lacer­
ation on the medial right lung. Two Alice clamps were placed on the
atrial wound for temporary hemostasis. The heart was closed using
prolene 3-0 suture in a running two layer fashion (Fig. 3). Wedge
resection was done for the lung injury. Pleural opening was closed and
drain left in the pericardial space. Hemostasis was achieved on the
sternum using bone wax and closed by wires. Superficial laceration over
his neck was washed and primarily repaired. Intraoperatively, he
required four units of whole blood transfusion.
After the procedure, the patient was successfully extubated and
transferred to intensive care unit. His first postoperative day was smooth
and uneventful in ICU. Echocardiography showed good function of
cardiac chambers, no valvular injury, and no thrombus. After three
uneventful postoperative days in ICU, the patient was transferred to
surgical ward and had his chest tubes removed on 6th day and dis­
charged on 7th day.
His outpatient follow up was also smooth. His last follow up was 18
months after surgery and he continued doing his regular job and daily
activities without functional limitations. His follow up echocardiogra­
phy, EKG and chest x ray were normal as well (Fig. 4).
Fig. 3. Sternotomy showing right artrial penetrating injury repair.

3. Discussion
patient 5 h out from trauma. But penetrating wounds in the anatomic
area known as the “cardiac box” should elicit highest levels of concern
Time from injury to surgery for penetrating cardiac injuries must be
for penetrating cardiac injury [5]. Focused and organized surveys as
short. In their study Andres Isaza et al. found the average was 60 min
well as resuscitation are valuable for any patent with penetrating
[3]. Penetrating cardiac injury survival is seemingly less likely in a
thoracic trauma.
Although many patients with penetrating cardiac injury might have
features of tamponade [3], it is not always easy to appreciate muffled
heart sounds in hectic trauma bays. In addition, if there is a hole in the
pericardium communicating with the pleural space the pericardial blood
may decompress into the pleural cavity and not be visible on ultrasound.
Hypotension too can be ascribed to associated traumas and factors. Ul­
trasound is easiest and non-invasive tool to examine the heart but it is
operator dependent.
With a patient in hemorrhagic shock and a penetrating wound near
the heart, a pericardial window is required regardless of the absence of
pericardial fluid on ultrasound and in this case proved to be lifesaving.
In situations where ultrasound is not available, pericardial window can
be helpful to rule out cardiac injury [6]. Median sternotomy is best and
reasonable approach for penetrating cardiac injuries since it provides
access to the heart, both pleura, great vessels and other mediastinal
structures [7]. Thoracotomy is acceptable as well but access to all sur­
faces of the heart may be more challenging.
The right ventricle is most commonly involved in penetrating cardiac
injuries [5]. Although its prevalence is low in most studies, others found
Fig. 1. Anterior chest stab wound.

2
A.G. Gucho and D.R. Jeffcoach International Journal of Surgery Case Reports 113 (2023) 109064

Consent

Written informed consent in a local language was obtained from the

patient for publication of this case report and accompanying images. A
copy of the written consent is available for review by the Editor-in-Chief
of this journal on request.

Ethical approval

Ethical approval was provided by the author's institution.

Source of funding

No source of funding.

Guarantor

David Jeffcoach, MD.

Provenance and peer review

Not commissioned, externally reviewed, reported as per SCARE

guideline.

Declaration of competing interest

The authors declare no conflicts of interest.

Fig. 4. 18 months after surgery.

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