Penetrating injury to the cardiac box and the deadly dozen
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Penetrating injury to the cardiac box and the deadly dozen Michael Nicoara, David Parizh, Vadim Meytes, Anthony Kopatsis Department of General Surgery, NYU Lutheran, Brooklyn, New York, USA Correspondence to Dr David Parizh, david.parizh@ nyumc.org Accepted 18 November 2016 To cite: Nicoara M, Parizh D, Meytes V, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2016-218361 DESCRIPTION A man aged 24 years who was assaulted was brought in by paramedics, boarded and collared, as a trauma notification. On primary survey, the patient was breathing spontaneously, saturating well on a non-rebreather mask. He had equal bilateral breath sounds with stable vital signs. On secondary survey, a 3 cm laceration was noted to the left of the sternal boarder at the fourth ICS. No active bleeding or evidence of sucking wound was evident. FAST examination was equivocal in the trauma bay. After obtaining a chest X-ray to exclude a pneumothorax and widened mediastinum, the patient was taken for a CT scan. Imaging was significant for an anter- ior 2 cm thick pericardial fluid collection and pneumomediastinum. An emergent median sternotomy was per- formed. Access was obtained in the standard fashion, and the pericardium opened. After evacu- ating the blood and unroofing the haematoma, a 2 cm left ventricular linear full thickness lacer- ation injury was noted to be actively bleeding ( figure 1, video 1). It was repaired with a pled- getted horizontal mattress using 3-0 prolene sutures ( figure 1). The patient transferred to surgical intensive care unit postoperatively for further monitoring. His hospital course was uneventful, and the patient was discharged home on the fifth hospital day. Figure 1 Median sternotomy revealing a left ventricular injury sustained from a stab wound (A) which was subsequently repaired (B). Video 1 Note the degree of exsanguination from a small defect in the left ventricle. Nicoara M, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-218361 1 Images in …
Transcript of Penetrating injury to the cardiac box and the deadly dozen
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Penetrating injury to the cardiac box and thedeadly dozenMichael Nicoara, David Parizh, Vadim Meytes, Anthony Kopatsis
Department of GeneralSurgery, NYU Lutheran,Brooklyn, New York, USA
Correspondence toDr David Parizh, [email protected]
Accepted 18 November 2016
To cite: Nicoara M,Parizh D, Meytes V, et al.BMJ Case Rep Publishedonline: [please include DayMonth Year] doi:10.1136/bcr-2016-218361
DESCRIPTIONA man aged 24 years who was assaulted wasbrought in by paramedics, boarded and collared,as a trauma notification. On primary survey, thepatient was breathing spontaneously, saturatingwell on a non-rebreather mask. He had equalbilateral breath sounds with stable vital signs. Onsecondary survey, a 3 cm laceration was noted tothe left of the sternal boarder at the fourth ICS.No active bleeding or evidence of suckingwound was evident. FAST examination wasequivocal in the trauma bay. After obtaining achest X-ray to exclude a pneumothorax andwidened mediastinum, the patient was taken fora CT scan. Imaging was significant for an anter-ior 2 cm thick pericardial fluid collection andpneumomediastinum.An emergent median sternotomy was per-
formed. Access was obtained in the standardfashion, and the pericardium opened. After evacu-ating the blood and unroofing the haematoma, a2 cm left ventricular linear full thickness lacer-ation injury was noted to be actively bleeding
(figure 1, video 1). It was repaired with a pled-getted horizontal mattress using 3-0 prolenesutures (figure 1).The patient transferred to surgical intensive care
unit postoperatively for further monitoring. Hishospital course was uneventful, and the patient wasdischarged home on the fifth hospital day.
Figure 1 Median sternotomy revealing a left ventricular injury sustained from a stab wound (A) which wassubsequently repaired (B).
Video 1 Note the degree of exsanguination from asmall defect in the left ventricle.
Nicoara M, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-218361 1
Images in
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Contributors MN contributed to analysis and interpretation of data, draftingthe article and final approval of the version to be published. DP contributed tothe conception and design of the study, acquired data analysis andinterpretation of data, drafting the article, revising intellectual content andfinal approval of the version to be published. VM contributed to analysisand interpretation of data, drafting the article and final approval of theversion to be published. AK contributed to acquired data analysis andinterpretation of data, drafting the article and final approval of the version tobe published.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCE1 Burack JH, Kandil E, Sawas A, et al. Triage and outcome of patients with mediastinal
penetrating trauma. Ann Thorac Surg 2007;83:37782.
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Learning points
1. The area bordered by the sternal notch (superior), xiphoid(inferior), nipples (lateral) is referred to as the cardiac box.1
2. The Deadly Dozen is a compilation of injuries to becognizant of in the work-up of a patient with a penetratinginjury to the cardiac box. They are further broken down intothe lethal six (airway obstruction, open pneumothorax,tension pneumothorax, cardiac tamponade, massivehaemothorax, flail chest) and the hidden six (aortic disruption,oesophageal injury, trachiobronchial injury, cardiac contusion,pulmonary contusion, diaphragmatic tear).1
3. Stable penetrating trauma to the cardiac box may benefitfrom screening TTE or CT angiography. Patients withnegative results may be monitored. Positive results will needfurther work-up and operative management as indicated.1
2 Nicoara M, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-218361
Images in
http://dx.doi.org/10.1016/j.athoracsur.2006.05.107
Penetrating injury to the cardiac box and the deadly dozenDescriptionReferences
