My Night on Call…Stabbed Heart

As I scrubbed out from a hernia repair approaching midnight, I had an urgent call from Trauma Resus – “Dr. Barnard, there’s a stabbed heart.”  As my heart also skips a beat I remember, this is what we’ve been trained to do.  I let anaesthesia know to keep the OR empty, and that the scrub team should get a thoracotomy set ready while I rush to an assessment in Casualty.

I find a young man with a precordial stab wound, and all of Beck’s triad (hypotension; elevated systemic venous pressure, often with jugular venous distention; muffled heart sounds) staring back at me, just like in a textbook. 

Minutes later, we’re rolling into the OR, transfusion protocol activated, the scrub-sisters already opening sterile drapes. 

I’m scrubbed before induction, I’ve seen trauma patients crash before and I don’t want to be caught off guard.  I’m ready for a speedy thoracotomy.

With a few sweeps of a blade and cautery, we’re in the thorax.  With lung-down ventilation this thoracotomy reveals a tamponading heart.  Fresh blood gushes out as I make my linear pericardial incision.  THERE IT IS! A small right ventricular stab wound.

Prolene and pledgets ready, I start my closure, remembering that the idea is for the heart to come to the needle, almost impaling itself in its efforts. 

The blood pressure starts picking up and the anaesthesia team alerts me they’ve started to taper their adrenaline.  I sigh with relief.  After inspecting for other injuries, I go back to examine my repair. The pledgets are sitting snugly on a dry myocardium.  ‘The universe still has big plans for this man’ – I whisper under my mask. 

The most difficult parts about a stabbed heart are the intuitive decision-making and keeping your calm as the lead surgeon.  It’s all a conglomerate of micro-decisions and the team will look to you for guidance. A combination of coordinated teamwork, an intimate knowledge of anatomy, technique, anticipation and just a little bit of luck goes a long way to ensure a good outcome.