Background Unintentional injuries remain the primary cause of death in individuals 1 - 34 years of age and thoracic injuries are the second leading cause of mortality. A focused assessment with sonography for trauma (FAST) exam is helpful in the diagnosis of pericardial effusion suggesting a cardiac injury in trauma victims. A positive FAST exam for pericardial effusion should be immediately followed by a pericardial window before proceeding with definitive treatment in the hemodynamically stable patient.
Methods We present the case of a 19 year-old woman who was transferred to our ED following a stab wound to the left lateral chest wall. Management of this patient included hemodynamic stabilization by infusion of crystalloids and blood products, multiple FAST exams and an exploratory laparotomy with a transdiaphragmatic pericardial window, all which failed to reveal an injury.
Results In the recovery room, the left chest tube output rapidly increased and the patient was immediately taken to the operating room for a thoracotomy where an occult left ventricular injury was discovered and repaired. During the operation, the patient underwent asystole and was resuscitated. The following day in the ICU, the patient expired following cardiac arrest.
Conclusion This case illustrates a common presentation of a patient with anterior chest trauma. FAST exam has a high negative predictive value for pericardial effusions. To our knowledge this is the first case of a penetrating cardiac injury in a patient with a negative pericardial window. Hypovolemic shock patients with a negative exploratory laparotomy and pericardial window should undergo a left thoracotomy to rule out an occult cardiac injury.
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