Perioperative airway and hemodynamic management of a retained thoracic foreign body (stab injury) with superior vena cava injury

Penetrating thoracic trauma involving the superior vena cava (SVC) is associated with significant morbidity and mortality. Achieving lung isolation in the presence of an anticipated or unanticipated difficult airway and hemodynamic instability presents a major anesthetic challenge. A 53-year-old man presented with an in situ knife fragment in the right infraclavicular region following an assault. Computed tomography demonstrated SVC injury with a metallic foreign body extending toward the superior mediastinum. An unanticipated difficult airway (Cormack–Lehane grade 3a) prevented double-lumen tube (DLT) placement. After successful single lumen tube (SLT) intubation, an EZ-Blocker was inserted under flexible fiberoptic bronchoscopic guidance to achieve one-lung ventilation. Right anterolateral thoracotomy facilitated controlled blade removal and primary SVC repair. Despite 1200 mL blood loss, hemodynamic stability was maintained with titrated noradrenaline and a restrictive transfusion strategy. The patient was extubated on post-operative day 2 and discharged from the intensive care unit on day 3. EZBlocker- assisted lung isolation through a SLT is an effective rescue technique when DLT placement fails during emergency thoracic trauma. Careful airway planning, reliable vascular access, and judicious vasopressor and transfusion management are essential for successful perioperative management of great-vessel injuries.