Abstract
Shrapnel injuries of the superior vena cava (SVC) are extremely rare and highly lethal. The true incidence is not known since many patients succumb shortly after injury. The high fatality is due to difficulty in diagnosis, technical problems with repair and consequences of SVC clamping. Literature review revealed no shrapnel SVC injury reported before. This is a report of 30-year-old man from Kirkuk, Iraq, a victim of terroristic attack who was admitted to Sulaimania Teaching Hospital (STH) on June 2007 with shock, massive right-side haemothorax and a wound at base of neck following a shrapnel injury. Emergency right thoracotomy revealed clotted haemothorax and big shrapnel partly sealing a tear in SVC just above the entrance of the azygos vein. Severe bleeding ensued after extraction of the shrapnel. Attempts to control the hemorrhage and repair of the injury failed and unfortunately, the patient expired in the theatre. Though there is no pathognomonic sign of SVC injury, it should be suspected in patients presenting with shock and haemothorax. Successful repair is achievable with early diagnosis, aggressive resuscitation, early exploration, optimum operating conditions and special measures such as auto-transfusion and cardiopulmonary bypass.
Highlights
Superior vena cava is vulnerable to injuries of different kinds
We report on a patient with isolated superior vena cava (SVC) injury by big shrapnel who expired in the operating theatre because of uncontrolled hemorrhage
The true incidence of penetrating wounds of the SVC as well as other great vessels is not known since many of these patients succumb shortly after injury and autopsy examination is not done in all patients dying after trauma [3]
Summary
Superior vena cava is vulnerable to injuries of different kinds. Most of the reported injuries are iatrogenic; resulting from placement of central venous catheters, insertion of pacemakers, stenting of SVC in SVC obstruction syndrome or placement of a filter in the SVC to prevent showering of emboli [1]. Blunt and penetrating trauma to SVC is rare and highly fatal [2]. We report on a patient with isolated SVC injury by big shrapnel who expired in the operating theatre because of uncontrolled hemorrhage. The case is presented with review of up to date medical literature. The aim is to recognize methods of early detection and measures of successful surgical repair
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