Anesthetic management of stab wound in right ventricle of heart

Case Report

A 28-year-old man with no known comorbid presented in emergency department with complain of pain over left side of chest following accidental stab trauma during a religious ceremony. Physical examination showed a stab wound on left side of anterior chest wall just next to sternal border with bulging of left side of chest; GCS of 15/15; heart rate of 112 bpm; blood pressures of 72/44 mmHg; oxygen saturation of 98% on face mask of 5 L/min oxygen; respiratory rate of 26/min, and decreased air entry on left lower hemithorax. Initial baseline blood investigations were normal and chest x-ray showed basal atelectasis on left lower lobe of lung. On echocardiogram, there was no pericardial effusion or other abnormality.

Patient was transported to operating room immediately for emergency sternotomy. In the operating room, routine monitoring was applied including electrocardiography, noninvasive blood pressure, pulse oximetry, and two large bore intravenous cannulas were inserted. His base line blood pressure in operating room was 90/50 mmHg, heart rate of 108 beats/min, and oxygen saturation was 98% on 5 L/min oxygen. Preinduction arterial line was inserted in left radial artery. Rapid sequence induction technique was used for induction of anesthesia. After preoxygenation, anesthesia was induced with midazolam, ketamine, succinylcholine, and nalbuphine. The trachea was intubated using rapid sequence induction and patient was mechanically ventilated. Central venous pressure (CVP) line was then inserted in right internal jugular vein and baseline central venous pressure was 19 cm of H₂O. On the basis of high CVP and hemodynamic instability, an initial diagnosis of impending cardiac tamponade was made. Although on preoperative echocardiogram, there was no pericardial effusion or other abnormality identified. Anesthesia was maintained with isoflurane with oxygen–air mixture and atracurium was used for muscle relaxant. Intraoperatively, ketorolac, and paracetamol were given for analgesia.

After sternotomy, it was found that the stab trauma had breeched the chest wall along with pericardium. After the opening of pericardium, 300 mL of fresh blood with clots were evacuated. CVP was then decrease to 6 cm of H₂O from 19 cm of H₂O. There was a laceration of about 2 cm just lateral to left anterior descending artery in right ventricle, which was then repair and closed with pledgets and sutures [Figure 1]. After securing the hemostasis, chest was closed. Fluid resuscitation was done with gelofusine (1 L) and normal saline 0.9% (1 L). Total blood loss was ~500 mL intraoperatively. Patient was shifted to cardiac intensive care unit (CICU) for further management. He remained stable in the CICU. Patient was weaned from ventilator and extubated a few hours later after fulfilling the extubation criteria. On first postoperative day, he was shifted to special care unit and was discharged on fourth postoperative day.

Conclusion

Stabbed hearts are surgical emergencies that require a prompt and focused anesthetic intervention. Maintenance of optimal blood volume and judiciary use of inotropes may be lifesaving. A systematic approach to these patients is necessary so that other life-threatening lesions are treated appropriately and in a timely fashion.