Unusual Delayed Manifestation of a Penetrating Chest Trauma

Abstract

Pericardial tamponade remains a diagnostic challenge to the clinician especially when the patient is well compensated hemodynamically. We report an unusual case who sought medical help 1 month after having been stabbed in his chest. An investigation revealed a perforation of the myocardium and a pericardial tamponade. The patient survived thanks to a large organized clot that plugged the perforation. The patient was exposed to increased risk due to delayed onset, recognition, and therapy of the tamponade. Most reports on this subject deal with acute pericardial tamponade. Only few cases of delayed pericardial tamponade have been reported. A review of the relevant literature and the therapeutic approaches are discussed. Case StudyA 18-year-old boy was rushed into the emergency department complaining of prolonged pain in his anterior chest and upper left abdomen, aggravating with respiration and position changes. His past medical history was uneventful.The patient was fully alert and cooperative, hemodynamically stable. A physical examination revealed an old surgical scar above the left nipple on the anterior chest that was firmly closed, clean, without infection or a leak. A yet unknown 1/6 high-pitched systolic murmur was detected. The rest of his physical examination and vital signs were normal. Laboratory studies showed abnormally high CK and LDH levels. ECG was normal.The patient was asked about the origin of the scar and admitted that he had been stabbed by a drunken man a month ago. He said that although the wound bled quite severely, he had not sought medical care because he was afraid of his parent's reaction. Ever since and until the last few days he felt well. A possible link between the past stab wound and his present complaint was immediately sought: a chest film revealed an enlarged cardiac silhouette which was interpreted, by a subsequent echocardiogram (Figure 1), as a large pericardial effusion (about 500 ml) constraining the right auricle. It also showed a large intrapericardial thrombus adhering the right ventricular wall plugging a mural perforation. A CT angiography confirmed the pericardial effusion but failed to demonstrate the other findings. It was concluded that the patient was having pericardial tamponade due to a leaking mural perforation of the right ventricle somehow plugged by a thrombus. The patient was immediately referred to a cardiac surgical department in another hospital where he was operated on. The pericardial content of blood and coagulates have been evacuated, a large organized thrombus (Figures 2, 3) was removed and the ventricular puncture was sutured. A 3 cm × 3 cm pericardial window toward the right pleural space was performed. The following recovery was uneventful.

Delayed Presentation of Cardiac Injury after a Penetrating Stab Wound to the Chest

“…The overall mortality is 47 per cent. 1 The majority of cardiac injuries are characterized by acute clinical manifestations and most patients undergo emergent surgical intervention. 2 The most common clinical signs of delayed pericardial effusion after stab wounds to the chest are dyspnea, distended neck veins, pleural effusion, and fever.…”