Delayed management of penetrating cardiac injury – Less urgency, more options

A 34 year old male sustained a stab injury to his left parasternal edge at the 4th intercostal space. Following a delay of 48 h, he presented to his local secondary hospital. At the time of admission he had a blood pressure of 73/38 mmHg – no other clinical signs of cardiac tamponade – and this normalised with intravenous fluids. Basic x-rays were performed and computed tomography (CT) of his chest was undertaken. This demonstrated a haemopericardium with left sided haemothorax (Fig. 1). Following, the patient was urgently transferred to our Level 1 Trauma Unit. On arrival, vitals were normal. Arterial blood gas results were pH 7.44, lactate 0.4 mmol/L and base excess 7.3 mmol/L. Electrocardiogram demonstrated T wave flattening at lead 3 and ST elevation at V3. Retrospective analysis of his chest X-rays from the secondary hospital revealed straightening of the left heart border, highly suspicious of haemopericardium. Transthoracic echocardiography was also performed and confirmed pericardial effusion. Troponin was elevated at 1.1 mg/L. The patient was taken to the operating theatre. A pericardial window was initially performed which demonstrated