Chest Pain and Dyspnea With a Piercing Diagnosis

Abstract

A patient presented to the ED with 2 days of chest pain radiating to the back. Symptoms were associated with dyspnea and diaphoresis. The patient had a significant history of self-inflicted stab wounds and retained foreign bodies. He was status-post multiple endoscopic removals and laparotomies. The patient was recently admitted to the hospital secondary to an abdominal foreign body removed by general surgery. The day of presentation the patient denied any new injuries. He had no history of cardiac disease or venous thromboembolic events. Review of systems was negative other than noted. His vital signs showed an initial BP 120/55, pulse rate 118, temperature 36.9 C, respiration rate of 20, and peripheral capillary oxygen saturation 97% on room air. His general appearance was significant for an ill-appearing, diaphoretic man. Cardiovascular examination was notable for sinus tachycardia with intact distal pulses and no detectable abnormal heart sounds. Respiratory examination revealed clear lungs and normal work of breathing. Abdominal examination revealed multiple well-healed scars without tenderness or peritoneal signs. The rest of his physical examination was unremarkable.On arrival to the ED, two large-bore IV lines were established. ST changes were noted on the monitor, prompting an ECG that revealed diffuse ST segment elevations. Troponin was elevated to 2.01. A bedside cardiac ultrasound was performed (Video 1).

Removal of sewing needles from interventricular septum under the guidance of multiple imaging modalities

“…Emergency surgery should be performed promptly in the case of cardiac tamponade or free wall rupture inasmuch as a needle penetrating the heart. 4,5 In most cases, it is essential to make incisions in the heart to remove a foreign body embedded in the IVS. 7 Combined with nonenhanced CT, TTE, especially TEE in the present case, was able to precisely locate the sewing needle in the IVS and to aid in removal without requiring incision into the heart, thereby diminishing trauma and facilitating rehabilitation.…”

“…Cardiac foreign bodies vary from bone cement, air bullets, metal splinters, and stents to needles and paperclips 1–5 . Penetration of the heart or left chest wall by sewing needles is extremely rare, and some of these incidents have been self‐inflicted injuries resulting from depression or drug abuse.…”

“…Although magnetic resonance imaging shows more detail, it has limited use in identifying a foreign body in the heart because the vital signs are usually unstable. Emergency surgery should be performed promptly in the case of cardiac tamponade or free wall rupture inasmuch as a needle penetrating the heart 4,5 . In most cases, it is essential to make incisions in the heart to remove a foreign body embedded in the IVS 7 …”

“…Penetration of the heart by a sharp foreign body is a life‐threatening emergency event, which could lead to heart transfixion, cardiac tamponade, endocarditis, cerebral infarction, and death 1–5 . Self‐inflicted injury is the cause in some cases.…”

“…Self‐inflicted injury is the cause in some cases. The most common locations are the right atrium, pulmonary artery, right ventricle, interventricular septum (IVS), and left side of the heart 4 . Herein, we report a case of sewing needles penetrating the IVS, which were successfully removed under the guidance of multiple imaging modalities.…”