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© 2004 European Association of Cardio-Thoracic Surgery
Penetrating pediatric cardiac trauma caused by fall on a pencil with normal echocardiographyDepartment of Cardiothoracic and Vascular Surgery, Virga Jesse Hospital Hasselt, Stadsomvaart II, Hasselt 3500, Belgium * Corresponding author. Tel.: +32-11-30-90-60; fax: +32-11-30-90-68. (E-mail: janderaet{at}hotmail.com). Received May 12, 2004; received in revised form June 28, 2004; accepted July 1, 2004
A toddler, age 2, presented with a penetrating cardiac trauma caused by a fall on a pencil. This case showed a normal echocardiography. However, during removal of the pencil, signs of cardiac tamponade were noticeable. Thus, a normal echocardiography is no guarantee to exclude a possible penetrating cardiac injury.
A boy toddler, age 2, presented to the emergency department approximately 30min after a fall from a flight of stairs which at first seemed to be a minor trauma. The child fell down with his chest on his right hand, while holding a yellow coloured pencil in his right hand. Physical examination showed an entrance wound at the second left intercostal space, with a piece of the coloured pencil enlodged inside the wound. The vital signs were normal and there were no signs of cardiac tamponade. The breath sounds and heart tones were normal. There was no subcutaneous emphysema present. A chest X-ray showed an intrathoracic foreign body with an entrance parasternal left at the level of the hilum of the left lung. It was directed to the right with a caudodorsal, pre- and paracardiac angle in the anterior mediastinum (Figs. 1 and 2). About 40min after the fall a transthoracic echocardiography (TTE) revealed no pericardial effusion. Blood was typed and cross-matched.
The child was immediately transferred to the operating room. Before removing the foreign body, the child was fully installed with optimal haemodynamic monitoring by means of an arterial and central venous line and a cardiopulmonary bypass machine with a perfusionist was stand-by. The pencil was then percutaneously very easily removed. The intrathoracic length of this pencil was about 10cm. After 2–3min, a progressive decrease of systemic arterial pressure and an obvious increase of CVP appeared. Signs of cardiac tamponade were noticeable. The hypothesis was that the pencil occluded the entrance site of a major cardiovascular structure, thereby preventing bleeding. An immediate sternotomy was performed. The pericardium was longitudinally opened during which an important quantity of fresh desaturated blood was evacuated. During inspecting, we found a bleeding at the auricle of the right atrium. The pencil entered the chest at the second left intercostal space, penetrated in the anterior mediastinum the pericardium above the ascending aorta and landed in the right auricle. Because of severe blood loss in this very young child, we used a temporary inflow occlusion to minimize the blood loss. After inflow occlusion, the bleeding was controlled with a Satinsky clamp. The inflow occlusion was relieved and the perforation at the auricle was primarily repaired with a running 4-0 monofilament non-absorbable suture. The haemodynamics of the patient were fully restored. The mediastinal space was rinced thoroughly with a betadine solution and a broad-spectrum antibiotic (amoxicillin-clavulanate) was started intravenously. A retrosternal and a pericardial chest tube were installed and the chest was closed. The patient was transported to the surgical intensive care unit for further monitoring. There were no problems and the patient was discharged to the pediatric ward for observation. The child recovered swiftly and could leave the hospital alive and well after 8 days.
Penetration of a foreign body in the heart may result from either direct injury to the heart or from embolization to the heart from distal penetration sites. This case presented a direct injury to the heart. A penetrating chest trauma with a foreign body should never be removed in the emergency department, even when the chest X-ray, laboratory tests and the echocardiography are within normal limits. The reason being that the foreign body, as in this case, may occlude the entrance site of major cardiovascular structures, thereby preventing bleeding. These foreign bodies should be removed in a fully equipped operating room where an immediate thoracotomy could be done, if the need should arise [1]. Major cardiac injury, which may cause fatal outcome, is rare during childhood. There are no clear diagnostic criteria for cardiac injury. For this reason, many incidental studies are reported from emergency departments, from autopsies, and intensive care units. 14.5% of pediatric trauma patients had cardiac trauma, and cardiac trauma accounts for 39% of mortality. Many other studies report cardiac injury cases after major blunt trauma to be 0–43% [2–7].
Cardiac perforation due to home accidents is extremely rare [8,9]. However, stabbing injuries of the chest with the physical findings should rise the suspicion for the possible trauma. It is obvious that echocardiography is mandatory in these patients after haemodynamic stability is achieved. The sensitivity and the specificity of echocardiography in diagnosing cardiac trauma are reported to be 90 and 97%, respectively [10]. It is obvious that early diagnosis is important for survival. In our patient, however, the echocardiography was within normal limits. It revealed no pericardial effusion. In conclusion, in every penetrating trauma to the chest with non-specific laboratory tests and even a normal echocardiography, the suspicion for a possible cardiac injury should always be kept in mind because there are always ‘false-negatives’. Early diagnosis may be life saving.
Author: Mr. Manoj Purohit, Blackpool Victoria Hospital, Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK Date: 23-Sep-2004 Message: The authors have presented an interesting case but I must say that they were brave and lucky to come out clean. It is well documented that the entry point was the 2nd intercostal space left side and the direction was caudodorsal, the pencil looked to be directed well into the middle mediastinum going posteriorly when seen in Pa and lat chest X-ray. With this position of impacted foreign body what was the clinical index of suspicion that there would be cardiac injury? The authors have documented well that echocardiography can be misleading but as only confined to the collection in pericardium, the echo is more sensitive for diagnosing the site of impaction, as ultrasound is very frequently used for guided procedures, Was this utilised? The authors have rightly pointed out that the only place to tackle this situation is a well equipped operating room but failed to comment on the anaesthesia part, which can be very tricky in such situations. The percutaneous removal of the impacted pencil and then waiting for signs of bleeding and tamponade before doing sternotomy is quite an aberrant approach. The ideal would have been the sternotomy and then removal under vision after completely identifying structures transgressed by the impacted pencil, which would not have been so difficult in a 2 year old child. After the gentle sternotomy, the left half of the sternum could have been lifted up to dislodge the pencil from it, leaving it impacted in the mediastinum. This would have resulted in less bleeding and easy identification of the site of cardiac injury. The need of inflow occlusion to control bleeding from the right auricle was a drastic step. I can only imagine that the need of inflow occlusion must have been because of the large amount of blood in the pericardial cavity causing difficulty in identifying the site of injury rather than because of the serious nature of injury. Was the inflow occlusion done before identifying the site of injury or afterwards? In an impacted foreign body, advantage of the situation should be taken to prevent bleeding and to identify the injured structures.
doi:10.1016/j.icvts.2004.07.013
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Abstract
1. Case report
n these situations, since the diagnostic role of invasive pericardiocentesis is limited, echocardiography remains the major non-invasive diagnostic tool for diagnosis of cardiac injury. 