Aabha Divya1, Niti Dalal2, Mona Swain3, Juhi Baktavar4
An 18-year-old man was shot with in the chest and was evaluated in the
emergency department two days after the incidence. The patient was
hemodynamically stable with normal sinus rhythm. He had a single penetrating
wound close to the left border of the sternum in the fifth intercostal space (Figure
1). A chest roentgenogram revealed foreign body between the cardiac silhouette
and diaphragm with mediastinal widening (Figure 2). Bilateral intercostal drainage
tubes were present in situ. Focused assessment with sonography in trauma (FAST)
was positive for pericardial effusion. The computed tomographic (CT) scan
revealed a pellet on the under surface of the heart with a tract through the left
lung; however, the artefact from the pellet made exact localization difficult (Figure
3).
Transoesophageal echocardiography revealed normal ventricular and valvular
function but with moderate pericardial effusion. There was no wall motion
abnormality and the foreign body was poorly visualized. Patient was taken to
operating theatre for emergency sternotomy. There was hemopericardium with
clots overlying the lateral and inferior surface of the heart. Suspecting possible
cardiac injury, he was placed on cardiopulmonary bypass via central cannulation.
On exposing the lateral surface of the left ventricle, an entry wound through the
posterolateral pericardium was identified. There was a tear in the left ventricle
approximately one centimetre from the interventricular groove close to the left
anterior descending artery (Figure 4). The wound was repaired with felt-reinforced
sutures. The pellet was identified in the pericardium after suctioning and it was
removed. The left pleura was opened. It revealed contusion in the left lower lobe
of the left lung. A small leak was identified and was repaired with interrupted
sutures. The patient was taken off of cardiopulmonary bypass after repair without
difficulty and was subsequently shifted to the ICU.
