Asian Cardiovasc Thorac Ann 1999;7:158-160
© 1999 Asia Publishing EXchange Pte Ltd
Penetrating Cardiac Injury Due to Ballpoint Pen
Ashutosh A Hardikar, MS,
Sanjeev S Thakur, MS,
Pushkaraj S Karmarkar, MS,
Vilas S Ambike, MS,
Ashok V Kanetkar, MS,
Keshaw B Golhar, MS
Department of Surgery
BJ Medical College & Sasson General Hospitals
Pune, Maharashtra, India
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For reprint information contact: Ashutosh A Hardikar, MS Tel: 61 8 8222 4000 Fax: 61 8 8222 5170 email: ahardika{at}mail.rah.sa.gov.au Department of Cardiothoracic Surgery, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.
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Abstract
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Penetrating cardiac injury has the highest mortality and morbidity rates of any organ trauma. We describe a case of cardiac injury presenting with partial pericardial tamponade, which was caused by penetration of a ballpoint pen. The injury was diagnosed by chest radiography and successfully treated in a non-cardiac setup. Urgent investigation and surgical intervention are emphasized.
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Introduction
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Penetrating cardiac trauma has the highest mortality and morbidity rates of all organ injuries.1–3 Although the pre-hospital mortality rate for penetrating cardiac trauma is estimated to be 70% to 80%, rapid transportation of patients to trauma centers and aggressive intervention have increased the number of patients who reach the hospital alive and survive.2,3
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Case Report
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A 17-year-old boy was knocked off his bicycle in a road traffic accident in Pune. Four hours later, he was admitted to the Sassoon Hospitals' casualty ward. He complained of something having entered his left chest, probably his ballpoint pen that had been in his left shirt pocket. On examination, he was hemodynamically stable with a regular pulse of 84 beats•min–1, blood pressure of 110/70 mm Hg, and a respiratory rate of 24 per minute. There was no pallor or neck-vein distention. An entry wound was detected in the 2nd left intercostal space, 5 cm from the midline. It was an elliptical wound of 1 cm in length. Beneath the skin nearby, a pointed object was felt moving with the cardiac pulsations. A penetrating mediastinal injury was suspected and a venesection was carried out for a central venous pressure measurement that was found to be 24 cm H2O. Urgent chest radiographs were taken in frontal and lateral views (Figures 1 and 2
). They showed a ballpoint pen over the heart shadow, extending from the anterior to the posterior mediastinum. There was an increased cardiothoracic ratio but his electrocardiogram was within normal limits. An adequate blood supply was kept ready and the patient was moved to the operating theater within one hour of admission to the hospital.
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Figure 1. Chest radiograph, frontal view, showing the metallic ballpoint pen overlying the cardiac shadow. Please note the mediastinal widening and site of penetration that explains the injury to the lingula found at operation.
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Figure 2. Chest radiograph, lateral view, showing the metallic ballpoint pen penetrating the cardiac shadow almost up to the posterior wall. This corresponds to the contusion found on the posterior left ventricular wall at operation.
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A left anterolateral thoracotomy was performed through the 4th intercostal space. A metallic ballpoint pen was seen passing through the anterior part of the lingula and entering the pericardium. The pericardium was opened and blood clots were removed. The pen was seen piercing the anterior basal segment of the left ventricle and it was removed after encircling it with a pursestring suture of 4/0 polypropylene. Additional interrupted sutures were required to achieve hemostasis in a 0.75-cm elliptical ventricular rent. A contusion was seen on the posterior wall of the left ventricle due to the tip of the pen. A pericardial window was created posterolaterally and the pericardium was closed. After securing hemostasis in the lung parenchymal rent, the thoracotomy was closed in layers over an intercostal drain inserted through the 8th intercostal space.
The patient made an uneventful recovery without arrhythmias or infection. The postoperative chest radiograph showed evidence of lung contusion and elevation of the left hemidiaphragm, which gradually recovered. The patient was discharged on the 13th postoperative day. A two-dimensional echocardiogram carried out 6 months later showed normal ventricular function.
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Discussion
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In one of the largest series of penetrating cardiac traumas, the Texas Heart Institute reported that 373 of 459 patients were dead on arrival at hospital.4 There are usually no survivors among those who arrive lifeless and survival is inversely proportional to the degree of shock. Some degree of tamponade prevents exsanguination, as was seen in our patient, and is therefore more common in survivors.5,6
The diagnosis in this case was based on the patient's history, the palpation of an object beneath the skin, chest radiographs showing the pen in situ, an increased cardiothoracic ratio, and raised central venous pressure. Although a wide range of objects including various blades, bullets, and other missiles have been reported as causing injury to the heart, such an injury from one's own ballpoint pen must be an extremely rare incident.3,5
This case demonstrates the role of partial pericardial tamponade in saving the patient's life and sustaining him in a hemodynamically stable state during transport to the hospital. The rapid use of all available investigative tools can also be lifesaving.7 By the time our patient reached the operating theater, the superficial end of the pen was no longer palpable. The contusion on the posterior wall of the left ventricle found at surgery indicates that the pen was gradually sucked into the ventricular cavity. Hence the need for urgent surgical intervention even in such hemodynamically stable cases, must be emphasized. Our institute does not have a cardiothoracic setup or an echocardiograph but it was possible to successfully treat this life-threatening cardiac injury without these facilities. It would always be advisable and safer to have a cardiopulmonary bypass machine on standby if possible. Our patient recovered without any postoperative complications such as coronary injuries, pericarditis, false aneurysms, arteriovenous fistulas, intracardiac damage, or damage to the conduction system as has been reported by other authors.8
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Acknowledgment
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We would like to thank our Dean Dr. Mrs. M.A. Phadke for allowing us to use the hospital records to present this case.
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References
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Harman PK, Trinkle JK. Injury to the heart. In: Moore EE, Mattox KL, editors. Norwalk: Appleton-Century-Crofts, 1986:365–84.
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Ivatury RR, Nalathambi MN, Rohman M. Penetrating cardiac trauma: quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61–6.[Medline]
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Sugg WL, Rea WJ, Ecker RR, Webb WR, Rose EF, Shaw RR, et al. Retrospective study of 459 cases of penetrating cardiac trauma. J Thorac Cardiovasc Surg 1968;56:531.[Medline]
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Symbas PN, Vlasis-Hale SE, Picone AL, Hatcher CR. Missiles in the heart. Ann Thorac Surg 1989;48:192–4.[Abstract]
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Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma 1986;26:821–5.[Medline]
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Gallahnejad M, Kutty ACK, Wallace HW. Secondary lesions of penetrating cardiac injuries. A frequent complication. Ann Surg 1980;95:902–7.
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Abstract
Introduction
