Clinical Case 086: from Hell’s heart I stab at thee

Today’s case is a tough one.  This is not a happy story, but can you make it end well?

So lets lay it out and narrow it down to a few key decision points.

The patient is a 35 year old woman with a long history of schizophrenia – she has suffered with persecutory, paranoid delusions for many years.  She also has a tendency to use alcohol to “self-medicate”.  She is closely monitored by a community mental health team and has been managed under a community-treatment order for the last few years.

Recently she has been under a lot of stress and she has increased her alcohol use.  You have seen her in ED a few times with self-inflicted injuries resulting from delusional actions.

Tonight she has been brought in by ambulance after another delusional, self-inflicted injury….

Our patient has taken a long blade and hammered it into her sternum using a heavy torch.  This happened at least 2 hours ago.  On arrival tot the ED her obs are remarkably normal.

Apart from a bit of blood on her clothing there is little else to find other than a knife handle protruding from her anterior chest.

As you are assessing her she has a transient dip in her BP – down from 110/80 to 85/70.  This recovers without any intervention on your part.

So she gets some big IVCs, a cross match is sent, and the cardio-thoracic Reg is paged to attend ASAP.

Her ECG is as shown here…

ECG

A quick FAST / ECHO show no fee fluid, no pneumothorax, and no pericardial effusion of any volume [no tamponade effect seen either] But…..  a spot troponin comes back at 0.18 – so must have some myocardial injury?

When the Surgical team arrives there is a case conference in the hallway….

They are keen to pull the blade in ED!  This seems like a bad idea…  after a bit of back and forth a CT is ordered

Here is a slice from the CT

CT CHEST

Lets assume we are in a tertiary ED with all the usual resources – ICU, cardiac theatre, trauma surgeons etc….

There was a similar case presented on Life in the Fast Lane a few months ago which you should check out for reference. There is  a great “what would Weingart Do?” session around this case.

Here are a my questions for this scenario:

Q1:  The super keen CT Reg is reassured by your limited bedside ECHO, and the CT appears to show no cardiac injury.  He wants to give a bit of sedation and pull it out in ED – no point in bothering the nice Anaesthetic team….    what do you say to him?

Q2:  Imagine you are the Anaesthetic Reg called to do a pre-op assessment for this lady.  What is your basic plan to prepare for  this case?

Q3:  NOW, just as you are “discussing” the management paln with the CT Reg – the nurse rudely interrupts you to say: shes just gone unconscious and has no palpable pulse!   Ah, bugger.  What to do now?  This is one of those scenarios that Cliff Reid bangs on about – you need to have a premeditated plan.  What is yours?  What kit do you need?  Do you know where it is in your department?

Q4:  Whose famous last words are included in the title of this post?

OK gang.  First in best answer – you know the drill

Cover yourself in Broome Docs glory and get your answers in.  Love and respect are your rewards.

Oh, and keep you eyes open for the brilliant FOAMed goodness that you can now get as the SMACC 2013 lectures are released on iTunes and the various super blogs.  There will be a lecture from Dr Scott Weingart on “Just Crack the Chest” in the near future – I will link back to this post when it is available.

Here is Scott on ED thoracotomy in NYC last year.  It is a biggish video so you will need a decent connection.

Cliff Reid’s “Making Things Happen” lecture was awesome – heres the link, then you will know what a ‘chicken bomb’ is!  You can learn how to get control in chaotic clinical situations.

And now a week later – I have caught up with my Rural Doc Posse – Dr Tim L and Dr Minh L.  WE recorded a 30 minute discussion on how we would approach this tricky case if it happened in a remote / rural hospital.  Here is the PODCAST with the lads.

Casey