SHOT IN THE CHEST, SAVED BY THE HEART

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Situs inversus, a rare autosomal recessive condition, has an incidence of 1:6000 to 1: 12,000 live births. [1,2] This case presents a rare scenario in which a patient who sustained a gunshot wound to the left side of his chest was saved by his previously undiagnosed medical condition. CASE PRESENTATION: A 28-year-old male with no reported past medical history presented to hospital after sustaining a gunshot wound to his left chest. On arrival, he was alert and oriented with a GCS of 15. He complained of severe left sided chest pain. His EKG (Figure 1) was suggestive of dextrocardia with a right axis deviation and lead I demonstrating inversion of the P wave. Figure 1: The EKG shows lead 1 with a negative P wave axis and negative QRS complex, with AVF showing a positive QRS deflection. Chest x-ray was significant for a large left sided hemopneumothorax, left rib fractures (6/12), and a left sided pulmonary contusion (figure 1). He underwent medical stabilization and chest tube placement which can be seen in (figure 2). A CT of the abdomen (figure 3) showed a left sided liver with grade 3 laceration; he also had a grade 1 left renal laceration with free air above the kidney. His thoracic and abdominal imaging demonstrated evidence of situs inversus totalis. The patient underwent a laparotomy, including a hepatic laceration repair, with placement of a left sided chest tube which drained 400 ml of blood. Despite surgical intervention and having the chest tube for 7 days, the patient had persistent drainage despite broad spectrum antibiotic therapy. He then underwent video-assisted thoracoscopic surgery (VATS) for evacuation of retained hemothorax. The patient recovered and was discharged with rehabilitation. DISCUSSION: Dextrocardia is defined as a cardiac position that is a mirror image of normal position. Situs inversus totalis is when thoracic and abdominal viscera are reversed including dextrocardia. Physical examination is significant for the presence of right-sided heart sounds on auscultation, with the apical impulse located on the right side of the chest. In addition to the physical examination, EKG supports the diagnosis of dextrocardia. EKG will show right axis deviation, an inverted P-wave and QRS complex in lead I, dominant S waves in leads I and V1 to V6, and reversed R wave progression in the precordial leads. CONCLUSIONS: This is the first report of a gunshot wound to the chest saved by undiagnosed condition of situs inversus totalis with dextrocardia. It is astonishing that this patient is alive and recovering due to the rare condition of dextrocardia with situs inversus. Had this patient had standard anatomy, he would have most likely died as the bullet would have directly pierced the heart. Reference #1: 1. Blegen HM. Surgery in situ s inversus. Ann Surg. 1949;129:244–59. [PMC free article] [PubMed] [Google Scholar] Reference #2: 2. Bohun CM, Potts JE, Casey BM, Sandor GG. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J Cardiol. 2007;100:305–9. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Bryan Curry, source=Web Response no disclosure on file for Joseph Reimon; No relevant relationships by Benjamin Sinyor, source=Web Response No relevant relationships by Balarama Surapaneni, source=Web Response