Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
CASE REPORT  
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 236-238
Bedside ultrasound diagnosis of intracardiac paperclip


Department of Emergency Medicine, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey

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Date of Submission27-Aug-2013
Date of Acceptance01-Mar-2014
Date of Web Publication16-Jul-2014
 

   Abstract 

Penetrating cardiac injuries are rarely reported in the literature. Foreign bodies are rarely seen in the heart and most patients with penetrating cardiac injuries die from hemorragic or pericardial tamponade before arriving at the hospital. Bedside ultrasonography is a highly valuable and readily learned tool that has expanded rapidly since its introduction more than 20 years ago. Our case was a 23-year-old convict brought to the emergency department (ED) with a history of continuous chest pain in the upper area of the left side of the chest for one week. Focused Cardiac Sonography (FOCUS) which was performed by emergency physician showed a strong echogenic linear structure with comet tail artifact, free floating in the mid-segment of the left ventricule. Exact localizations of the paperclips within the chest was obtained with multidetector computed tomography and one of them was seen in the left ventricular cavity. FOCUS plays a crucial role in these patients by diagnosing the injury and detecting the complications in emergency department.

Keywords: Bedside ultrasound, emergency, foreign body

How to cite this article:
Unluer EE, Karagoz A, Topal FE, Akyol PY. Bedside ultrasound diagnosis of intracardiac paperclip. J Emerg Trauma Shock 2014;7:236-8

How to cite this URL:
Unluer EE, Karagoz A, Topal FE, Akyol PY. Bedside ultrasound diagnosis of intracardiac paperclip. J Emerg Trauma Shock [serial online] 2014 [cited 2020 Aug 12];7:236-8. Available from: http://www.onlinejets.org/text.asp?2014/7/3/236/136873



   Introduction Top


Penetrating cardiac injury is a highly lethal trauma. This type of injuries are rarely reported in the literature. Foreign bodies are rarely seen in the heart. The symptoms due to a foreign body in the heart can present from hours to years. [1] These foreign bodies can be asymptomatic even after several years. [2] Most of the cases were accidental or self-inflicted due to an underlying psychiatric illness. [3] Here, we present a patient who had intracardiac foreign body diagnosed by emergency physician with bedside ultrasound.


   Case report Top


A 23-year-old convict was brought to the emergency department (ED) with a history of continuous chest pain in the upper area of the left side of the chest for one week. His history revealed that self-injurious behavior while in jail. He denied any illicit drug use. The patient appeared well and his vital signs were stable. Physical examintaion has revealed normal findings except the presence of eight puncture sites on the skin to left of the middle sternal border [Figure 1]. Further questionining revealed the reason of these injuries and he accepted having inflicted his present injury on himself by paperclips.
Figure 1: The puncture sites on the patient's skin to left of the middle sternal border

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Electrocardiography was normal and Focused cardiac sonography (FOCUS) was performed by emergency physician using an M7R ® model ultrasound machine with a 3.6-MHz microconvex transducer (Mindray Bio-medical Electronics Co., Shenzhen, China) and ultrasonographic views were recorded. FOCUS have showed no pericardial effusion, normal regional and global left ventricular function, and a strong echogenic linear structure with comet tail artifact, free floating in the midsegment of the left ventricule [Figure 2]. A routine chest X-ray showed seven paperclips within the chest, six of them superimposed on the cardiac silhoutte [Figure 3]. Exact localizations of the paperclips within the chest were obtained with multidetector computed tomography and one of them was seen in the left ventricular cavity [Figure 4]. Cardiovascular surgeons recommended an operational removal of the paperclip to the patient and he refused the operation. He is anticoagulated and discharged from hospital with a follow-up plan.
Figure 2: The ultrasonographic image of patient's heart. White arrow shows the echogenic linear structure with comet tail artifact in the mid-segment of the left ventricule

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Figure 3: Chest X-ray of the patient showing seven paperclips within the chest, six of them superimposed on the cardiac silhoutte

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Figure 4: Exact localizations of the paperclips within the chest was obtained with multidetector computed tomography. Multiple paperclips seen in chest cavity (Figure 4a, white arrow) and one of them was seen in the left ventricular cavity (Figure 4b, white arrow)

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   Discussion Top


Bedside ultrasonography is a highly valuable and readily learned tool that has expanded rapidly since its introduction more than 20 years ago. Nowadays, it has lent itself to the evaluation and management of most patients through the incorporation of multiple ultrasound examinations within a single patient encounter. [4],[5],[6] The information gained can provide crucial information at the bedside, which can enhance diagnostic certainty and guide management.

Foreign bodies are rarely seen in the heart and most patients with penetrating cardiac injuries die from hemorragic or pericardial tamponade before arriving at the hospital. Sewing needles, bullets, pellets, misseles, and pencils have been reported as foreign bodies penetrating the heart. [7],[8] Most of the cases were accidental or self-inflicted due to an underlying psychiatric illness. [3] Multiple puncture sides in a patient with a history of antisocial personality may suggest the possibilty of self injury. Bedside ultrasonography is a valuable tool for emergency physician (EP) for early diagnosis of both foreign body and also early complications such as cardiac tamponade. A further potential complication is thrombus formation around the needle or in the chambers of the heart which may embolise distally. [9] Since our patient refused the operational removal of the foreign body, we have decided to give prophylactic anticoagulation and antibiotic therapy. [1] Radiologic demostration of the foreign body is important to guide surgical treatment. Altough the chest radiograph confirms the nature of the injury, exact compartmental location should be assesed by computed tomography.

FOCUS plays a crucial role in these patients by diagnosing the injury, detecting the complications such as tamponade and also possible thrombus formation around the foreign body or in the cavities of the heart.

 
   References Top

1.Wang X, Zhao X, Du D, Xiang X. Management of metallic foreign bodies in the heart. J Card Surg 2012;27:704-6.  Back to cited text no. 1
    
2.Sayin AG, Beşirli K, Arslan C, Cantürk E. A case of intramyocardial sewing needle extracted without stopping the heart. Injury 2002;33:276-7.  Back to cited text no. 2
    
3.Schechter DC, Gilbert L. Injuries of the heart and great vessels due to pins and needles. Thorax 1969;24:246-53.  Back to cited text no. 3
[PUBMED]    
4.Gün C, Unlüer EE, Vandenberk N, Karagöz A, Sentürk GO, Oyar O. Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury. J Emerg Trauma Shock 2013;6:195-8.  Back to cited text no. 4
    
5.Ünlüer EE, Karagöz A, Bayata S, Akoğlu H. An alternative approach to the bedside assessment of left ventricular systolic function in the emergency department: Displacement of the aortic root. Acad Emerg Med 2013;20:367-73.  Back to cited text no. 5
    
6.Unlüer EE, Bayata S, Postaci N, Yeşil M, Yavaşi Ö, Kara PH, et al. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure. Emerg Med J 2012;29:280-3.  Back to cited text no. 6
    
7.Sbokos CG, Azariades M, Chlapoutakis E, Vomvogiannis A, Nomikos I, Andritsakis G. The removal of sewing needles from two children's hearts. Thorac Cardiovasc Surg 1984;32:373-5.  Back to cited text no. 7
[PUBMED]    
8.Datta G, Sarkar A, Mukherjee D. A foreign body in the heart. Arch Cardiovasc Dis 2011;104:684-5.  Back to cited text no. 8
    
9.Perrotta S, Perrotta A, Lentini S. In patients with cardiac injuries caused by sewing needles is the surgical approach the recommended treatment? Interact Cardiovasc Thorac Surg 2010;10:783-92.  Back to cited text no. 9
    

Top
Correspondence Address:
Erden Erol Unluer
Department of Emergency Medicine, ?zmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.136873

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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