Delayed Detection of a Ventricular Septal Defect Following Penetrating Trauma
Terrell Caffery, MD; Danny Robinson, MD; Hollis O’Neal Jr., MD, MSc; Azheem Kahn, MD; Scott Thurston, MD; Mandi Musso, PhD
This is a case report of a 27-year-oldmale who sustained a stabwound to the chest with a resulting penetrating cardiac injury and subsequent emergency thoracotomy. The patient survived his injury and on post-op day two, a holosystolic murmur was noted during physical exam, but he remained hemodynamically stable and intubated. A transthoracic echocardiogram revealed the presence of a ventricular septal defect (VSD), with Doppler flow revealing shunting from the left ventricular cavity into the right ventricular cavity. Ultimately, the clinicians decided upon a trial of extubationwith a plan for delayed closure of the VSD. Upon extubation, the patient became hypoxemic with evidence of pulmonary edema; thus, he was re-intubated. The defect was surgically repaired, and the patient had an uneventful recovery thereafter. The purpose of this case report is to present an example of delayed detection of a ventricular septal defect after a penetrating cardiac injury.
INTRODUCTION Penetrating thoracic trauma is one of the most com- mon causes of major cardiac injury and is becoming more prevalent in the emergency setting, especially in areas where violent crimes occur frequently. 1 A large majority of these patients (up to 94%) die before they reach the hospital. 2 For patients who survive long enough to make it to the hospital and receive an emergency thoracotomy, mortality rates are estimated to range between 81%-92%. 3-5 Delayed sequelae of cardiac injury include ventricular dilation, ventricular dys- function, septal hypokinesia, pericardial effusion, 6 valve in- sufficiency, abnormal ST-T, conduction defects, myocardial infarction, cardiomegaly, paradoxical septum, arrhythmia, and ventricular septal defects (VSD). 7 The purpose of the current case is to present a patient with delayed detection of a traumatic VSD who was stable while under positive pressure ventilation but quickly became unstable with the physiological change to negative pressure ventilation. CASE REPORT A 27-year-old male presented to the emergency de- partment after sustaining a single stab wound to the chest. Upon arrival, the patient had an unobtainable blood pres- sure, heart rate of 110 beats/minute, and respirations of 20 breaths/minute. His initial Glascow Coma Score was 11, with eye opening to speech, verbal confusion, and with- drawal from pain. A 2 cm vertical stab wound was noted to the left, upper chest wall at the fourth intercostal space. Lung sounds revealed decreased breath sounds on the left. Heart sounds were undetectable. The patient had no other noted injuries.
After Advanced Trauma Life Support protocol was initiated, tube thoracostomy was performed on the left chest with some air return. At this time, the patient lost consciousness and became apneic. The emergency physician then performed an emergent thoracotomy, which revealed cardiac tamponade due to a hemopericardium. This was emergently treated with opening of the pericardial sac and evacuation of the effusion. A two centimeter laceration to the myocardium was noted and was rapidly repaired with a skin stapler and five purse-string sutures. The patient was intubated immediately following the initial emergency repair of the heart andwent into ventricular fibrillation. Car- diac massage was initiated, and the patient was defibrillated with 200 Joules/biphasic. After defibrillation, normal sinus rhythmwas noted on the monitor, with visual confirmation of organized cardiac activity. Pulses were palpable, and transfusion of blood was initiated. Cardiothoracic surgery was consulted and arrived to take the patient to the operating room for exploration and definitive repair of the heart. Initial evaluation by the surgical consultants revealed that the emergent closure was adequate with no further bleeding. Therefore, it was determined that no further explorationwas necessary at that time. The surgical site was irrigated and closed. Afterwards, the patient was admitted to the intensive care unit (ICU) for management of hypothermia, hypovolemic shock, and postoperative care. While in the ICU, it was found that the patient had visual deficits but was recovering well from the operation. Computed tomography of the head without contrast revealed two areas within the left parietal and right occipital lobes with low attenuation, likely representing areas of encephalomalacia.
J La State Med Soc VOL 166 November/December 2014 239
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