Management of Penetrating Right Atrial Injury: Anesthetic Considerations and Pitfalls

INTRODUCTION

Bullets or other sharp objects are the common causes of penetrating injuries to the anterior chest.¹ The extent of internal organ injury and the expertise of the treating clinicians largely influence the outcome and management of penetrating thoracic trauma. Penetrating thoracic trauma encompasses a wide clinical spectrum ranging from minor injuries to potentially fatal conditions.^2,3 In such cases, rapid assessment for major vascular damage is critical. Associated injuries to neural, pulmonary, and esophageal structures may also occur.⁴ In our patient, despite penetrating injury to the right atrium, he remained hemodynamically stable, which is rather unusual.

CASE REPORT

A 26-year-old male was brought to the trauma emergency department with a penetrating chest injury inflicted by a knife following a family dispute. The knife had penetrated the anterior chest wall and remained in situ at presentation. The patient was lying supine, conscious, and oriented. The entry wound was located just to the right of the midline in the fourth intercostal space [Figure 1]. There was no exit wound, swelling, or visible injury over the lateral or posterior chest wall. Approximately 5.6 cm of the knife protruded from the exterior. The patient was tachypneic with a respiratory rate of 26 breaths/min but was hemodynamically stable, with a heart rate of 79 beats/min, blood pressure of 122/74 mmHg, and SpO₂ of 92–94% on a face mask delivering 6 L/min of oxygen. Bilateral air entry was present, though decreased on the right side. No other external injuries were noted. The patient complained of severe pain, which was managed with intravenous fentanyl through an 18-gauge intravenous cannula, since the vein caliber of 16-gauge size was not appreciated in the patient.

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Figure 1:

Stab injury with a knife (arrows) at anterior of the chest at trauma emergency.

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Per institutional protocol, since the patient was hemodynamically stable, computed tomography (CT) [Figure 2a and b] was performed without changing the patient’s position, revealing no evidence of airway injury. A sharp hyperdense object was seen penetrating the anterior chest wall and extending up to the right atrium. Chest roentgenogram demonstrated a radio-opaque object extending into the right atrium without involvement of the posterior chest wall [Figure 3a and b]. Additional findings included mild right pleural effusion, pneumomediastinum, and mild right-sided pneumothorax. Preoperative hematological and biochemical investigations obtained in the emergency department were within normal limits, with hemoglobin of 12.2g/dL. The patient was transferred to the cardiothoracic operating theater for surgery. The perfusionist was called, and cardiopulmonary bypass was kept on standby.

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Figure 2:

(a and b) Computed tomography chest showing a hyperdense structure piercing the right atrium. ICS: Intercostal space.

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Figure 3:

(a and b) Chest X-ray showing knife like object embedded in situ (arrows).

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The patient was shifted onto the operating table, maintaining the supine position and ensuring that there was no movement of the impaled object. Standard monitoring was instituted, and baseline parameters were recorded. A 16-gauge intravenous cannula was secured in the left forearm. After preoxygenation with 100% oxygen, anesthesia was induced with fentanyl 100 µg, thiopentone 100 mg, and vecuronium 7 mg. Induction with thiopentone was chosen because the patient had a history of seizures and was on antiepileptic medication. With cricoid pressure applied, laryngoscopy was performed, and the trachea was intubated with a 37 Fr left double-lumen tube (DLT), with correct placement confirmed and secured. DLT was used to achieve right lung collapse and to prevent the knife from dislodging during surgical removal. A 7.5 Fr triple-lumen central venous catheter was inserted into the left internal jugular vein under ultrasound guidance, and the right radial artery was cannulated for invasive blood pressure monitoring. A transesophageal echocardiography (TEE) probe was inserted under laryngoscopic guidance. The patient was positioned in the supine position with slight elevation of the right hemothorax, and the DLT position was reconfirmed. Intraoperative TEE examination revealed a hyperechoic streak-like structure within the right atrium with post-acoustic shadow [Figure 4]. The free wall of the right atrium appeared immobile, with an echogenic area within the atrial cavity suggestive of clot formation. No mitral, tricuspid, or aortic regurgitation was observed, and there were no regional wall motion abnormalities. There was no evidence of pericardial effusion, and biventricular function was preserved.

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Figure 4:

ME4C view showing the knife (red arrow) penetrating to the right atrium (white arrow).

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An incision was made in the right groin for cannulation of the femoral artery and vein, and should cardiopulmonary bypass be required. A right mini-thoracotomy was then performed. On exposure, the knife was found to have penetrated the right lung parenchyma and extended into the right atrium.

The right lung was isolated to facilitate a motionless surgical field. Intrathoracic clots were evacuated, following which the knife was carefully withdrawn, followed by suturing of the right atrium wall. The impaled object appeared to be a kitchen knife, approximately the length of a scalpel. Standard closure was performed. Local infiltration with bupivacaine 0.25% (15 mL) was administered at the incision site. The patient remained hemodynamically stable throughout the procedure, with adequate oxygenation and normal arterial blood gas values at the conclusion of surgery. The surgery was completed in approximately 2.5 h, with no significant blood loss and no requirement for blood and blood products. Intraoperative TEE confirmed a normal right atrium with complete resolution of the previously visualized hyperechoic structure [Figure 5]. Neuromuscular blockade was reversed with neostigmine 3mg and glycopyrrolate 0.6mg, after which the patient was extubated and transferred to the postoperative intensive care unit for monitoring with supplemental oxygen. The postoperative course was uneventful, and the patient was discharged on the 6^th day of admission.

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Figure 5:

ME4C view after removal of the knife from the right atrium. RV: Right ventricle, RA: Right atrium.

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DISCUSSION

Thoracic trauma may present as a blunt or penetrating injury.⁵ Approximately 70% of thoracic injuries are blunt, while the remaining are penetrating.² Penetrating chest injuries are most commonly caused by stabbing with sharp objects or weapon-related trauma. Stab injuries usually result in localized damage limited to structures directly in the path of penetration, as opposed to other penetrating injuries, such as gunshots, which can cause extensive tissue damage due to cavitation.⁶ The primary objective of successful trauma management is early identification of life-threatening conditions. General principles in the management of penetrating trauma include avoiding movement of the impaled object, refraining from removing the penetrating object before definitive diagnosis, and securing the airway when indicated. A significant proportion of mortality in penetrating thoracic trauma results from major vascular injury.⁷ Therefore, careful assessment of vital signs, prompt volume resuscitation with fluids and blood and blood products, and early transfer to the operating room are essential once organ injury is suspected or confirmed. Post-traumatic intrathoracic injuries vary in severity. Pneumothorax is the most common thoracic complication, followed by hemothorax.⁸ Other potential complications include lung contusion, cardiac tamponade, pneumomediastinum, esophageal injury, spinal cord injury, and vascular injury.⁹

Gupta et al. reported a case of stab injury to the chest by a sickle following a fall from height.¹⁰ The sickle was left in situ, and the patient remained hemodynamically stable before being taken up for emergency surgical exploration and removal. Intraoperatively, a rent in the left pleura and diaphragm was identified and repaired. A comparable case described by İlhan et al. involved a 30-year-old man who sustained a stab wound to the back, with a knife penetrating the thorax paravertebrally between the scapulae.¹¹ CT revealed no vascular or vital thoracic organ injury. The knife was carefully removed in the operating theater, and pressure dressing was applied to the wound. These reports reinforce the principle that a diagnosis should be confirmed before removing a penetrating object.

In the present case, the knife penetrated the anterior chest wall and extended into the right atrium, as confirmed by CT. The patient was transferred promptly to the operating room with minimal manipulation. The knife was left undisturbed in its position to maintain a tamponade effect on the injured cardiac structure and minimize bleeding. The TEE demonstrated a hyperechoic structure partially dividing the right atrium into two parts. A right mini-thoracotomy was planned, with femoral-femoral cardiopulmonary bypass kept on standby in anticipation of potential massive hemorrhage. The patient was exceptionally fortunate, as the penetrating knife reached the right atrium without causing blood exsanguination into the pericardium, which could have resulted in pericardial tamponade and subsequent hemodynamic collapse. In this context, TEE played a pivotal role in serially assessing the position of the foreign body and cardiac integrity, including the interventricular septum and valves. Equally critical was the prevention of iatrogenic injury during transport, positioning, and surgical manipulation, all of which were carefully managed, which likely contributed to the favorable outcome.

CONCLUSION

Penetrating chest injuries require a high index of suspicion for associated intrathoracic visceral injury, as signs and symptoms may be subtle or misleading. The use of various imaging techniques, particularly intraoperative TEE, allows precise localization of the foreign body and assessment of cardiac chambers. Penetrating objects should not be removed/ manipulated from their original position before anesthetic induction and surgical exposure, as even minor displacement may exacerbate injury to adjacent structures. Premature removal of the impaled object may release the tamponade effect and precipitate catastrophic hemorrhage. Meticulous assessment, careful planning, and coordinated multidisciplinary management are essential and can significantly reduce intraoperative complications and improve patient outcomes.