Cardiac injuries remain the most challenging of all injuries seen in the field of trauma surgery. Penetrating injury to the heart generally occurs less frequently than blunt injury and most commonly injures the large anterior right ventricle. We present an unusual, and to our knowledge a previously unreported, cause of cardiac penetrating trauma in a child, involving a hooked needle (a 15 cm long, metallic device usually used for crocheting or lacemaking). A ventricular septal defect was managed conservatively shortly after the primary cardiorrhaphy. Evaluation methods for this rare presentation and its possible surgical treatments are discussed.
- cardiac injury
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Cardiac injuries remain the most challenging of all injuries seen in the field of trauma surgery and their management often requires immediate surgical intervention, excellent surgical technique, and the ability to provide excellent critical care to these patients postoperatively.1 Penetrating injury to the heart generally occurs less often than blunt injury and most commonly injures the large anterior right ventricle.2 Sewing needles,3 steel splinters,4 and crossbow bolts5 have been reported among foreign bodies penetrating the heart. Causes such as complication of a pectus excavatum operation, or an endomyocardial steet strut have been reported,6 although the most frequent causes of penetration are gunshots and stab injuries.7,8 Both Beck’s triad and Kussmaul’s sign are difficult to see in young children.2
We present an unusual and to our knowledge a previously unreported cause of cardiac penetrating trauma in a child, involving a hooked needle (a 15 cm long, metallic device usually used for crocheting or lacemaking). A ventricular septal defect (VSD) was managed conservatively shortly after the primary cardiorrhaphy. Evaluation methods for this rare presentation and its possible surgical treatments are discussed.
A 5 year old girl was admitted to our emergency department with a hooked needle penetrated in her chest wall from the left edge of the sternal corpus, in a mediolateral and craniocaudal trajectory (fig 1). The accident had happened when she fell over while running at home with a hooked needle in her hand, just 40 minutes before admission.
The child was conscious and fully alert. She did not have respiratory distress except for mild pain during breathing. Her blood pressure was 105/60 mm Hg, and the heart rate was 120 beats/min. The exposed part of the hooked needle had a movement reflecting the pulsatile motion of the heart. There were no other cranial or abdominal pathological findings. Both lungs were well aerated, heart sounds were clearly heard without any murmur, and the heart was rhythmic on auscultation. After venous access was secured, a portable electrocardiography was performed and a normal sinusal rhythm was seen. Anteroposterior and lateral chest radiography revealed penetration of the sternal corpus and the possibility of cardiac penetration (fig 2). Cardiac and upper abdominal ultrasound (US) performed subxiphoidally did not reveal any pericardial fluid, haemothorax, or intra-abdominal free fluid, but the tip of the hooked needle was visible inside the right ventricle. A central venous route was accessed via the left subclavian vein and the central venous pressure was measured as 6 cm H2O. The blood count was in the normal range (haematocrit 35%, haemoglobin 11 mg/dL, white blood cell count 10.1/m3). The computerised tomography (CT) scan showed a foreign body passing through the sternal corpus, and the tip of the hooked needle was in the right ventricle. The possibilities of pericardial tamponade, pneumothorax, and pleural effusion were excluded (fig 2).
The patient, who was conscious and in a stable condition, was taken to the operating room 40 minutes after admission. Gentle removal of the foreign body in the operating theatre was planned under mild anaesthesia, with conditions for general anaesthesia set in place in case of emergency. Four minutes after removing the hooked needle, a sudden bradycardia developed and central venous pressure rose to 15 cm H2O. The patient was intubated endotracheally and a left anterolateral thoracotomy via Sparango incision was performed. During the thoracotomy, pericardial tamponade was eased by pericardiotomy. There was a perforation measuring 3×4 mm on the anterior wall of the right ventricle, which was repaired with horizontal Halsted mattress sutures, (Prolene no. 2-0), without need for a pericardial patch. The patient was taken to the intensive care unit (ICU) postoperatively.
After two uneventful postoperative days in the ICU, the patient developed tachypnoea and dyspnoea with auscultable rough crackles from either hemithorax. Consultation with the paediatric cardiology unit (PCU) revealed congestive heart failure, thus intravenous dopamine and dobutamine treatment was started. Echocardiography was performed the same day and showed a traumatic VSD of 3.5 mm in length in the muscular portion of the interventricular septum with rough margins and an evident left to right shunt with a pressure gradient of 77 mmHg. The right ventricle was mildly dilated and its anterior wall hypokinetic. The ejection fraction was found to be 67% (fig 3).
The treatment in the ICU relieved the symptoms and the child was discharged to the PCU with no surgical problem on the sixth postoperative day, continuing on digoxin, captopril, and prophylaxis for endocarditis.
After 30 days of follow up in the PCU, the anti-congestive therapy was stopped. The patient was discharged with an asymptomatic patent VSD, and close six monthly follow up with echocardiography for the first year was planned.
Penetrating cardiac trauma in children is seldom reported in the literature and the incidence of penetrating cardiac trauma in children is lacking.2 Data on the effects of acute traumatic injury to specific cardiac components come mostly from the adult literature and consists of atrioventricular valve insufficiency, aortic insufficiency, VSD, atrial septal defect, coronary artery injury, haemopericardium, cardiac rupture and cardiac contusion.1,2,9
Physiological condition, cardiovascular respiratory score and mechanism of injury plus initial rhythm are reported to be significant predictors of outcome in penetrating cardiac injuries in adults.8 The case presented here, and our experience in cardiovascular trauma surgery supports that these predictive factors are strongly reliable. We also agree that the critical time period of pericardial tamponade acts on the patients’ outcomes as a positive or negative predictive factor.
There are several methods of evaluating cardiac injuries. Subxiphoid pericardial window remains the gold standard of all procedures for the diagnosis and treatment but with the availability of ultrasound (US) in trauma centres, this technique has been relegated to a second line of evaluation.1 Surgeon performed US decreases the time between arrival and definitive treatment in patients with penetrating cardiac traumas.10
Three categories of electrocardiographic (ECG) interpretation exist in penetrating cardiac trauma pre and post operatively: acute myocardial infarction, pericarditis, repolarisation unspesific changes.11 But ECG abnormalities are said to occur less commonly in children than in adults,2 as we experienced.
Two dimensional echocardiography has been shown to have a 90% accuracy, a 97% specificity, and a 90% sensitivity in detecting penetrating cardiac injuries by Jimenez et al.12 Unfortunately we could not perform an echocardiography preoperatively because of the course of our cases, but echocardiography gave us the chance of detecting the VSD postoperatively, and we believe that it must be the first choice as a diagnostic tool in the follow up period of patients’.
Chest CT has been shown to have a high sensitivity, spesificity and accuracy rate in the setting of penetrating thoracic injury.13 CT findings of our patient were the same as we detected in the operation. We think that CT scans can be used for diagnosis of a haemodynamically stable patient who can be closely monitored during the transfer and scanning period.
Unlike our case, emergency department thoracotomy can be used as a diagnostic and therapeutic tool in unstable patients and it continues to be widely used in children.1
Haemodynamically stable selected patients with isolated penetrating cardiac injuries can be followed up conservatively in ICU as in penetrating abdominal injuries. Series aiming to emphasise the point that there is a place for conservative management of selected cases with penetrating cardiac injuries has been reported,14 and we will report the results of our conservative management in penetrating cardiac trauma in the near future. Therefore, we tried to give the chance of non-operative management to our patient, but due to the reasons mentioned above, thoracotomy was performed.
Another point of debate is the reparation of injuries with life threatening free wall wounds of the heart. It is usually quite hard to detect accompanying intracardiac lesions in emergency surgery situations because of the negative effects of increased operation time to the traumatic patient. Intraoperative cardiac sampling following penetrating wound as a technique for early detection of traumatic intracardiac shunts in a case has been reported.15 In the literature numerous studies have reported residual intracardiac lesions which are not identified in the first operation from 4% to 56% of cases. Functional sequelae in such patients have rarely been described.11,16
Tesinski reports that almost 25% of the patients are later diagnosed to have suffered injury also to one of the intracardiac structures, a VSD caused by penetrating injury to the heart is found to in 2–10% of the survivors and interval repair should be performed according to the clinical status of the patient and mostly depends on the size of the left to right shunt.3 Delayed repair of cardiac trauma allows tissue healing to a varying degree which may or may not be beneficial. VSDs can shrink or even close spontaneously with time, but this is unlikely to occur with tricuspid valve injuries.17
We agree the authors who are in favor of delayed repair as it is more rationalist to repair residual intracardiac lesions in an elective operation. However the patients should be followed closely for delayed sequel of these lesions in a multidiciplinary fashion.
Competing interests: none declared