A case of penetrating cardiac injury (IIIb) discharged on foot

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  • 独歩退院した鋭的IIIb型心損傷の1例

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We report a case of a teenage male with penetrating cardiac injury (IIIb) . He injured himself when he slipped and fell down the stairs into a display case. The glass shards pierced the region around his sternum, and he was transported to the Emergency and Critical Care Center of this hospital. Upon arrival at the hospital, the patient's level of consciousness was 10 on the Japan Coma Scale. His blood pressure was 80 mmHg; he had a heart rate of 130 bpm and decreased breath sounds in his right lung. He was given a rapid fluid infusion intravenously. Echocardiography did not reveal any accumulation of pericardial effusion. Chest drainage was performed because a portable chest X-ray revealed a massive right hemothorax. Tracheal intubation was also carried out simultaneously. The chest tube drained 1700 ml of blood when inserted. As the patient responded to infusion and blood transfusion, contrast-enhanced computed tomography scans of the chest and abdomen were taken. The patient went into shock again upon returning to the emergency room, and a decision to perform thoracotomy for hemostasis was made. Through a right anterolateral thoracotomy from the site of incision, pericardial bleeding was ascertained and diagnosed as Type IIIa right atrial damage (The Japanese Association for The Surgery of Trauma, Organ Injury Classification 2008). Transverse sternotomy was performed successively making this a clamshell thoracotomy. Insertion of the index finger into the damaged area of the right atrium stopped the bleeding, and the wound area was then clamped with Satinsky forceps. The damaged site and pericardium were sutured before the chest incision was closed up. The patient progressed favorably and was ambulant at discharge on postoperative day 15. The present case was complicated by mild pericardial damage but it happened to progress without developing into cardiac tamponade, and the hemothorax was of the type that bled slowly into the thoracic cavity; hence, the patient did not experience cardiopulmonary arrest. The key to saving the lives of patients with penetrating trauma is the execution of uninterrupted rapid emergency care and hemostasis by a trauma team.

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