RT Journal Article
SR Electronic
T1 Crossbow bolt injury to the heart
JF Trauma Surgery & Acute Care Open
JO Trauma Surg Acute Care Open
FD BMJ Publishing Group Ltd
SP e000301
DO 10.1136/tsaco-2019-000301
VO 4
IS 1
A1 Deanne Jacobs
A1 Claire Hardman
A1 Syed A Zaman
A1 Akpofure Peter Ekeh
YR 2019
UL http://tsaco.bmj.com/content/4/1/e000301.abstract
AB Case summary A 33-year-old woman was transferred from an outside hospital with a penetrating injury to her right chest. The patient was shot with a crossbow with the entry site to the right breast/chest and a transmediastinal trajectory. She was intubated prior to arrival due to difficulty breathing. Her vital signs remained stable and within normal limits, with good breath sounds, and no evidence of pneumothorax on chest X-ray. The tip of the bolt was palpable at the patient’s left midaxillary line. Chest X-ray in trauma bay showed the transmediastinal trajectory, and the bolt appeared to have a field point (not a broadhead point) (figure 1). A CT of the chest was obtained to assist with surgical planning. Images showed the bolt penetrating the right chest, right ventricle and inferior aspect of the left ventricular muscle, through the stomach, and ending near the tip of the spleen with a fracture of the left seventh rib (figure 2).Figure 1 Image A shows the bolt (crossbow arrow) entering the patient’s right breast and chest. Image B is the chest X-ray taken in the trauma bay showing the transmediastinal trajectory and partial visualization of the tip of the bolt with a field point. Image C demonstrates the tip of the bolt after removal.Figure 2 CT of the chest with intravenous contrast showing a foreign body penetrating the right chest at the fourth intercostal space, right ventricle, left ventricle muscle, left hemidiaphragm, through the stomach, and ending near the tip of the spleen without injury to it. There was also a fracture of the lateral seventh rib and hemopericardium. The tip of the bolt is not clearly demonstrated due to artifact.What would you do?Median sternotomy followed by midline laparotomy.Clamshell thoracotomy in the Emergency Room (ER).Right anterolateral thoracotomy.Left posterolateral thoracotomy.