Indian Journal of Thoracic and Cardiovascular Surgery 1989-90; 6:106-108

An Unusual Case of Transfixation Injury of the Right Atrium and Lung AMIT BANERJEE KSVK SUBBA RAO M NACHIAPPAN

ABSTRACT: A ca se o f t r a n s f i x a t i o n i n ju ry o f the hea r t and lung c a u s e d b y a s p e a r is

r epor ted . A bu l lock -ca r t p r o v e d h a n d y to t r anspor t the pa t i en t wi th a 2 - m e t r e - l o n g spea r

impa l ed in the chest . W i t h d r a w a l o f the spea r o n l y a f t e r t h r a c o t o m y was an essen t ia l

s tep in the m a n a g e m e n t and con t r i bu t ed to the success fu l o u t c o m e . B o t h r ight a t r i um

and lung had w o u n d s o f en t ry and ex i t w h i c h is unusua l .

KEY WORDS'. heart injuries; thoracic injuries; transportation of patients; trauma; wounds and injuries; wounds, penetrating

INTRODUCTION

Impalement injuries to the thorax are uncommon and very few cases are documented. Such injury transfixing the heart or great vessels has an extremely high mortality t'2. We report an unusual case of a transfixation injury of the heart caused by a spear.

CASE REPORT

A 46-year-old man was assaulted with a spear in a family feud. It had been driven through the middle of his sternum with its 2-metre-long shaft protruding perpendicularly out of his chest (Fig.l). The same weapon had earlier been used in assaulting the victim's father who had subsequently succumbed to extensive intra-abdominal trauma.

From the Department of Cardiothoracic Surgery, Jawahar- lal Institute of Postgraduate Medical Education and Research, Pondicherry, India.

Address for correspondence : Dr Amit Banerjee, Associate Professor, Department of Cardiothoracic Surgery, JIPMER Hospital, Pondicherry 605 006, India.

Fig.l Spear shaft perpendicularly protruding from the patient's chest

The patient had been transported to the hospital atop an open bullock-cart as attempts by the villagers to dislodge the weapon had failed. Its length was not cut short for fear of mutilation of legal evidence.

When first examined in the emergency room nearly four hours after the incident, the patient was

Transfixation injury of right atrium 107

found conscious and well-oriented though tachy- pnoeic and in obvious agony. He was in a state

,of hypovolaemic shock. There was no clinical evidence of pneumothorax or pericardial tamponade though pericardial rub could be heard.

Since a cardiac injury with sustained blood loss was suspected, immediate surgical exploration was decided upon. The stretcher carrying the patient had to be placed on the floor of the elevator (in order to accommodate the projecting weapon) while trans- porting him to the cardiothoracic operation theatre.

Owing to the technical difficulties envisaged in sternotomy, an anterolateral thoracotomy was planned. Based on positive pleurocentesis, the right side was explored. The pleural cavity contained about 1.5 litres of unclotted blood. The tip of the spear had impaled the right paravertebral recess trans- fixing the lung, the pericardium and the heart. The wounds remained effectively plugged preventing any air leak or further active bleeding. The pericardium was slit open and the weapon carefully extracted. Retracing its path of penetration was difficult because it had a barbed tip. The right lung, right atrial appendage and right atrial body were found torn at two places each representing the wounds of entry and exit of the spearhead. The bleeding wounds in the atrial body and appendage could be separately clamped without much further loss of blood.

The atrial and pulmonary wounds were repaired with polypropylene sutures. The sternum which was partially fractured with avulsion of the fifth costal cartilage did not require any wiring. Once lost volume had been replaced and the vital parameters had stabilised, the pericardium was repaired and the chest closed with an intercostal drain. The skin around the wound of entry was debrided and sutured.

Fig.2 Spearhead with a barbed tip

Parenteral administration of antibiotics was started during surgery and continued postoperatively.

The spear had an iron head 40 cm long mounted on a bamboo shaft. It had a sharp, barbed tip (Fig.2). Such spears are used by fishermen to immobilise big catches and sometimes also for hunting small game.

Postoperatively, the patient had nonspecific atrial rhythm disturbances which settled within 48 hours. He developed fulminant infection in the wound of assault. Escherichia coli was grown which responded to specific therapy. Its source could possibly be the contaminated tip of the spear which had penetrated the caecum of the patient's deceased father. Fortunately, there was no systemic, mediastinal or pleural infection and the patient could be discharged in about three weeks' time.

DISCUSSION

Most of the penetrating chest wounds are stab injuries caused by knives 2. Mediaeval weapons such as arrows producing thoracic injuries are sparsely reported 3. However, we could not find any instance of thoracic impalement caused by a spear. A weapon of assault piercing the sternum was found unique to this case and we found none other documented. Multiple injuries 'to the same cardiac chamber caused by a single assault was also found to be unusual, if not unprecedented.

Demetriades and van der Veen 2 have described the invariable association of pulmonary lacerations with cardiac injuries. Hence the presence of pneumothorax and pericardial tamponade must always be looked for and if need be, tackled as part of the initial resuscitation.

As high as 77 per cent of cases with penetrating cardiac injuries reportedly die before medical at- tention 2'4. We attribute this to the immediate withdrawal of assault weapons leading to fatal exsanguination from the wounds. It was fortunate that attempts to dislodge the spear had failed in our patient. This substantially controlled the continued loss of blood. We wish to emphasise that

108 Banerjee et al

whenever there is a penetrating injury apparently involving the heart or great vessels, it may be prognostically advantageous to remove them under controlled conditions of a well equipped cardio- thoracic theatre. There should be facilities for instituting emergency cardiopulmonary bypass, if the need arose.

Hyde et al t have suggested that the impaling object be suitably cut to facilitate transportation. In the present case there was the peculiar situation of the object in question being a homicidal weapon. Sawing off a portion of the shaft could invite legal censure. In such a situation, the vintage bullock- cart came to the patient's rescue where an ambulance would have failed.

Wound sepsis is a well-known complication of surgery for penetrating injuries 2. Infection is more likely when the offending missile is a contaminated one. The tip of the spear injuring our patient had been contaminated with enterogenous micro-organ- isms. It was lucky that the patient escaped a life- threatening systemic infection. However, this experience has prompted us to obtain a wound swab for culture and sensitivity in such situations. The

use of prophylactic antibiotics is recommended in these cases 1.3.

We consider this case worth reporting not only because of the unusual weapon of assault but also the nature of injury and other interes- ting aspects of its presentation as well as mana- gement.

References

1. HYDE MR, SCHMIDT CA, JACOBSON JG, VYHMEISTER EE, LAUGHLIN LL. Impalement injuries to the thorax as a result o f motor vehicle accidents. Ann Thorac Surg 1987; 43: 189-90.

2. DEMETRIADES D, VAN DER VEEN BW. Penetrating injuries of the heart: experience over two years in South Africa. J Trauma 1983; 23: 1034--41.

3. VISWANATHAN R. Penetrating arrow injuries. Br J Surg 1988; 75: 647-8.

4. DEMETRIADES D, RABINNOWITZ B, MARKIDES N. Indica- tions for thoracotomy in stab injuries of the chest: a prospective study of 543 patients. Br J Surg 1986; 73: 888-90.