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Cardiac Penetrating Injury in a Eight Year Old Boy

M. Al. Blanaru, O. Bulat, S. Veringa,

Pediatric Surgery Department, Bacau, Romania

 

Correspondence:

Mircea Blanaru

Pediatric Surgery Department, Pediatric Hospital

Str. Spiru Haret nr. 2, Bacau, Romania

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract

We present the case of an 8 year old boy who accidentally fell from a tree and arrived at the hospital with severe hemorrhagic shock. Urgent surgery was performed and a cardiac penetrating wound was found.

 

Introduction

Trauma is the leading cause of mortality in patients younger than 18 year old. Although thoracic trauma accounts for only 5-12% of admissions to a trauma center, head injury is the second common cause of death. Multisystem involvement is reported in more than 50% of children with thoracic trauma and the mortality for isolated thoracic trauma is 5%. It approaches 20-35% in the cases with concomitant abdominal or head injuries, respectively. Penetrating trauma comprises 15% of chest injuries in children, most due to gunshots, knife wounds, and injury from other sharp objects. Regardless of the mechanism of thoracic trauma, 15% of children do not survive [1, 2]. These patients require emergent medical intervention because of the possible mortality [3, 4].

Case report

We present a case of an eight year old boy who was admitted in the emergency department with severe hemorrhagic shock. His past medical history did not show any striking impairment. The history of present complaint revealed that he had fallen from a tree from about four meters height one hour admission to the hospital. He presented abdominal and head trauma. On physical examination we found:

- Oozing from an epigastric dilacerated wound, 3 centimeters in diameter;

-Diffuse pain in the upper abdomen, epigastric guarding;8 Abdominal dullness;

- Hypotension (60 mm Hg), tachycardia (180/min), cold and pale extremities, unconsciousness.

A major abdominal trauma with internal hemorrhage from a ruptured parenchymatous organ was suspected and the patient was planned for urgent laparotomy. First resuscitation measures were undertaken immediately in AE department: double venous access, naso-gastric suction, oro-tracheal intubation and mechanical ventilation. Despite intensive care measures with 80 ml/kg crystalloid solutions, the patient remains hypotensive and develops ventricular arrhythmia and flutter.

In this dramatic situation the surgery was decided. A xifo-umbilical incision was performed. A medium amount of blood (400 ml) is evacuated from the abdominal cavity; a thorough examination of intra abdominal organs in order to locate the source of bleeding was carried out but no cause was discovered. At the examination of the diaphragm, fresh blood was gushing through the Larey opening. Through a median sternotomy the pericardium is opened and a small amount of blood was removed. The heart had weak and irregular contractions and a large occlusive clot was firmly attached to a vertical cut on right ventricle. The clot was removed and the left index was introduced through the ventricular wound to control bleeding. The heart muscle was closed using 7/0 nylon separate stitches, taking care of not interfering with coronary vessels. A good haemostasis was acquired and the contractions of the heart became rapidly more vigorously. The pericardium was drained and closed with catgut, the thorax and the abdomen closed.

The patient was under antibiotics (cephalosporin) for 5 days and heparin for the first postoperative days. Daily drainage from the pericardium was under 3 ml of blood and it was withdrawn in the third postoperative day. EKG returned to normal during the operation and remained normal.

The patient was discharged from hospital in the ninth day. He was seen in the outpatient clinic after a month presenting full recovery.

Discussions

The case we presented was initially thought to be a major abdominal trauma with internal bleeding due to a hepatic injury with a dramatic presentation of a hemorrhagic shock intertwined with neurologic impairment due to a possible head trauma. The vital risk of the possible hepatic injury forced us to operate this patient as no US or CT-scan were available.

From the patients’ entourage resulted that the wound was caused by a tree knob which injured the epigastric area and also contributed to the body orientation to a head first landing.

Somatic and neurologic lesions which occurred rapidly in this case embracing the form of neuro-vascular stupor can explain the clinical signs of an acute abdomen, with guarding. On the other hand, the complex trauma this patient suffered can be accountable for lack of classical signs of a specific organ lesion.

Hepatic trauma must be always suspected when haemothorax, costal fractures and pelvic bones or vertebral column fractures are also present, especially when the mechanism of injury is falling down from height. More over, arterial hypotension in a patient with paraplegia can obscure the blood loss due to vasodilatation. Therefore additional laboratory and imagistic tests are indispensable.

In our case the necessity of immediate action deprived us of any other valuable information which would have assisted in diagnosis. Perforating heart wound has a dramatic presentation but when there are associated other injuries the mortality increases up to 80%. Scorpio et al. reported that in 14.5% of paediatric trauma patients had cardiac trauma, which gives 39% of mortality. Many other studies report that cardiac injury cases after major blunt trauma are 0-43% [5].

Penetrating wounds can involve any of the 4 chambers of the heart but are most common in the right ventricle due to its anterior location. The presence of hemopericardium on transthoracic echo or subxiphoid pericardial window mandates urgent sternotomy or thoracotomy for repair of cardiac injury. Sternotomy is advantageous because it provides a good access to all cardiac chambers and, if necessary, institution of cardiopulmonary bypass [1, 6].

Cardiac tamponade can be suggested by persistence of hypotension despite large amounts of substitutive fluids and jugular veins engorgement. The classic presentation described by Beck – high venous pressure, hypotension and ‘silent’ heart – arrhythmias on EKG, is not always exposed [7]. The definitive diagnosis of cardiac tamponade is made by pericardiocentesis, which is also the initial treatment measure which will get us time for gaining additional tests and resuscitative measures.

CONCLUSIONS

1. A penetrating abdominal wound associated with signs of haemorrhagic shock requires aggressive diagnostic measures and treatment.

2. Perforating heart wounds are dramatic in presentation but when immediate action is undertaken survival is possible.

3. Heart wounds when correctly treated have a good immediate and long standing prognosis with “restitutio ad integrum” without any sequela.

 

 

REFERENCES

  1. Mahesh S Sharma, MD et al, Division of Cardiothoracic Surgery, Children’s Heart Institute, Methodist Children’s Hospital of San Antonio, Thoracic Trauma, August 27,2008
  2. Scorpio, Ronald J. M; Wesson, David E. MD, FRCS (C); Smith, Charles R. MD, FRCP (C); Hu, Xiaohan MPH, PhD; Spence, laura J. BScN, Blunt Cardiac Injuries in Children: A Postmortem Study,Journal of Trauma Injury Infection and Critical Care. 41 (@): 306-309, August 1996
  3. Dowd MD, Krug S. Pediatric Blunt Injury: epidemiology, clinical features and diagnosis. J. Trauma 1996; 40: 61-70
  4. Cooper A, Foltin GL. Thoracic Trauma. In: Barkin A., editor. PediatricEmergency Medicine: Concepts and Clinical Practice. St Louis: Mosby; 1992. P. 261-75.
  5. Ildstad S.T. Tollerud D.J. Weiss R.G., et al. Cardiac Contusion in Pediatric Patients with Blunt Thoracic Trauma. Pediatr. Surg. 25: 287-289,1990.
  6. Smith GA, Salness RA. Cardiac Truma. In: Pine JW, editor. Moss and Adams Heart Disease in Infants, Children and Adolescent. Baltimore: Williams and Wilkins; 1995. P 1521
  7. Tellez D.W., Hardin W.D., Takahashi M. et al. Blunt Cardiac Injury in Children. J. Pediatr. Trauma Surg. 32: 1123-1128, 1987.