Stab Wound to the Heart: An Easy Diagnosis with EKG and CXR

Abstract

A 35-year-old man presented to our Emergency Department approximately 12 hours after multiple self-inflicted stab wounds to the left upper quadrant with a 6” knife. Although he claimed to have intended to kill himself at the time, he was happy to be still alive at his time of presentation. His main complaint at this time was increasing chest pain, made worse by deep inspiration and relieved slightly upon sitting forward. On examination, he was generally well but with a slight tachypnoea of 16–18 breaths per minute. He was well perfused and warm with a blood pressure of 120/85 and a pulse of 90 beats per minute, regular. Abdominal examination revealed a mildly tender left upper quadrant. Cardiac examination was essentially normal, with good heart sounds and no raised jugular venous pressure. EKG revealed widespread ST segment elevation, in the typical “saddle-shape” associated with pericarditis (Fig. 1). Chest x-ray (CXR) showed an apical pneumothorax, pneumomediastinum, and a pneumopericardium, but no other collections (Fig. 2). FAST ultrasound did not demonstrate a hemopericardium. A chest drain then was inserted into the left hemithorax. The presumed diagnosis in this patient was pericarditis secondary to the penetrating injury the evening before. The patient thus was taken to surgery and a laparotomy was performed, revealing a small amount of peritoneal blood. There was no damage to the abdominal organs, but there was a small traumatic incision in the left hemidiaphragm (Fig. 3). A pericardiotomy was performed, revealing a small amount of blood and fibrin remnants. Thus, a median sternotomy was performed to explore the heart, and a small bleeding point