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A 46-year-old male was admitted to the emergency department after

he was stabbed into the left thorax, lateral to the xiphoid and medial to

the mammary line. Initial diagnostics included immediate transthoracic

two-dimensional echocardiography and multiphasic multidetector CT of

the thorax. The latter showed pericardial fluid during the early arterial

phase and effusion of contrast medium into pericardium and pleural

space during the late phase.

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pericardial fluid during the early

arterial phase

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effusion of contrast medium

into pericardium and pleural

space during the late phase

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The patient was transferred to the operation theatre foremergency left-sided thoracotomy at the fifth intercostal

space. Surgical pericardiotomy was performed and massive

amounts of blood and blood clots were evacuated. The situs

confirmed ventricular perforation, approximately 3.5 cm from

the apex, that was surgically closed by sutures. Intermediatedefibrillation re-established adequate cardiac rhythm that was

then maintained throughout the surgical procedure onto ICU

admission. The patient received intensive care and was

extubated two weeks later.

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penetrating injuries to the heart are fatal (80%) and represent an

increasing cause of traumatic deaths in urban areas.

They are categorized as eithergunshot orstab wounds.

Gunshot wounds usually double or quadruple the mortality of

stab wounds this phenomenon may be attributed to the

surrounding tissue injury caused by high-velocity projectiles versus

the low velocity of a stab instrument causing less extensive tissue

damage.

,a review of 1802 cases of penetrating cardiac trauma indicated the

right and left ventricles to be injured in 43% and 30% of cases,

respectively.

For the atria, right-sided lesions were found in 14% of cases and

left-sided lesions in 5%.

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There are three typical manifestations of penetrating cardiac injury:

(i) hemorrhage, (ii) pericardial tamponade, and (iii) the combination

of both. Or Asymptomatic

Hemorrhage may lead to shock while pericardial tamponade is

classically associated with Becks triad . decreased blood pressure,

increased central venous pressure, and distant heart sound,

Additional clinical features include paradoxical pulse and lowvoltages.

However, there is quite a substantial number of patients that does

not exhibit symptoms suggestive of cardiac injury or penetration .

Although highly indicative for tamponade, Becks triad occurs only

in 10% of all patients .

Due to the muscular nature of the ventricle walls lacerations

following stabs often seal temporarily thus allowing time for

transportation. This is in contrast to the thin atrial walls

Manifestations and complications

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Initial assessment in the trauma usually includes TTEechocardiography which was found to have a greater than 90%

accuracy, specificity, and sensitivity for the diagnosis of cardiac

penetration.

In selected cases and if the patient is compensated andhemodynamically stable, contrast-medium enhanced

multiphasic CT may be used to localize the site and extent of

the injury as well as to exclude other relevant pathologies, i.e.

pulmonal lesioning.

Other strategies such as pericardiocentesis, ECG and chestradiography are of limited value as they are associated with

high rates of false results and non-specificity.

Investigations

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Several prognostic factors have been identified for survival and

outcome in patients with penetrating cardiac trauma:

(1) Mechanism of injury, i.e. gunshot versus stab wound ,

(2) Location of injury, i.e. right versus left ventricle,

(3) Complexity of injury, i.e. single-chamber versus multi-chamber

and/or intrapericardial great vessel injury including aortic injury, (4) Time ,

(5) Presence or absence of vital signs upon ED admission

(6) Absence of cardiac arrhythmia

(7) Pericardial tamponade limiting exsanguination into the lefthemithorax

Prognosis

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We report on a patient who survived a cardiac stabwound, obviously due to a combination of circumstances

known to be associated with favorable outcome:

immediate and qualified prehospital care.

On site the patient was immediately seen by anexperienced emergency physician who stabalized vital

parameters followed by quick transfer to the nearestLevel I trauma center, according to the scoop and run-principle.

the injury pattern comprised an isolated stab wound tothe right ventricle.

the patient did not develop arrythmia, excepttachycardia due to hypovolemia and pericardialtamponade, the latter limiting exsanguination into thethorax.