Successful Management of Penetrating Right Ventricular Stab Injury with Cardiac Tamponade in a Resource-Limited Setting: A Case Report

Introduction

Penetrating cardiac trauma is one of the most lethal forms of injury, with reported mortality ranging from 16% to over 80%, largely because many patients die before reaching definitive care.¹ Outcomes among hospital arrivals are determined by the mechanism and location of injury, associated extracardiac trauma, the presence of cardiac tamponade, and the time to surgical control of bleeding.² Series consistently report that the right ventricle is the most frequently injured chamber in penetrating cardiac trauma, reflecting its exposed anterior position behind the sternum.²

Cardiac tamponade is a double-edged phenomenon in this context. It can transiently limit hemorrhage and thereby provide a window for survival, yet rapid accumulation of blood within the pericardial sac quickly impairs ventricular filling and may precipitate obstructive shock or cardiac arrest.³ Clinical manifestations are often incomplete, and the classic Beck triad may be absent in trauma patients, making reliance on physical examination alone hazardous.³ Consequently, focused assessment with sonography for trauma (FAST) and bedside transthoracic echocardiography have become central to contemporary algorithms for suspected penetrating cardiac injury, allowing rapid identification of pericardial fluid and guiding the choice between temporizing measures and immediate surgical exploration.^1,4

Timely access to these diagnostic and therapeutic resources is not universal. In many low- and middle-income countries, emergency care for penetrating chest trauma is delivered in resource-limited hospitals where advanced imaging may be unavailable or delayed, cardiopulmonary bypass is not routinely accessible for emergency trauma surgery, and blood products and highly specialized cardiothoracic support are constrained.^1,5 Under such conditions, clinicians must often make high-stakes decisions based on clinical assessment, basic monitoring, plain radiography, and bedside ultrasound, using conventional surgical instruments rather than specialized cardiac trauma equipment.^1,5 Reports from such settings have shown that, despite these constraints, survival is achievable when a high index of suspicion is combined with early ultrasound and prompt operative intervention.^1,5

We report the successful beating-heart repair of a penetrating right ventricular stab injury with cardiac tamponade in an adolescent patient managed at a Somali tertiary hospital without immediate access to cardiopulmonary bypass. The case illustrates how a streamlined resuscitation and operative pathway—anchored in bedside ultrasound and rapid sternotomy—can be implemented in this environment, and it highlights practical considerations for hemodynamic management and myocardial repair that may inform care in other low-resource settings.^1,5

Case Presentation

A 15-year-old boy with no known prior medical illness was brought to the emergency department approximately 3 hours after sustaining a single stab wound to the left anterior chest during an assault (Figure 1A). He was not taking regular medications and had no history of allergy, prior surgery, or bleeding disorder. Prehospital transport was non-medical, and no invasive prehospital intervention had been performed before arrival.

Figure 1 (A) Stab wound on the left anterior chest wall. (B) Initial chest X-ray showing enlarged cardiac silhouette.

On presentation, he was conscious but agitated and pale. His blood pressure was 80/60 mmHg, heart rate 110 beats/minute, respiratory rate 26 breaths/minute, and peripheral oxygen saturation 94% on room air. A single approximately 2-cm stab wound was noted in the left fifth intercostal space at the midclavicular line (Figure 1A). Heart sounds were markedly muffled, there was no obvious massive external bleeding, breath sounds were present bilaterally, and the abdomen was soft without clinical distension or guarding.

Initial resuscitation included supplemental oxygen, two large-bore intravenous cannulas, isotonic crystalloid infusion, blood sampling and grouping/cross-matching, urgent surgical review, and bedside imaging. Hemoglobin and coagulation studies were not available before transfer to theatre because of the need for immediate intervention. Plain chest radiography demonstrated an enlarged cardiac silhouette without clear pneumothorax or major hemothorax (Figure 1B). Extended FAST was then performed: pericardial views showed a large effusion with echogenic clot suggestive of hemopericardium and tamponade (Figure 2), thoracic views did not show a significant pleural fluid collection, and abdominal views did not demonstrate free intraperitoneal fluid.

Figure 2 Echocardiogram demonstrating hemopericardium with clot.

Given persistent hypotension, the presence of intrapericardial clot, and the immediate availability of surgical exploration, definitive sternotomy was chosen over pericardiocentesis. In this setting, pericardiocentesis was considered only a potential temporizing measure and was less suitable because clot evacuation and direct control of cardiac bleeding were required. The patient was transferred urgently to the operating room. General anesthesia was induced with careful hemodynamic support, continuous electrocardiographic and pulse oximetry monitoring were used, and blood products were prepared for transfusion according to availability.

Median sternotomy and pericardiotomy released a large volume of blood and organized clot from the pericardial sac. Exploration identified a 1-cm laceration on the anterior surface of the right ventricle close to the left anterior descending coronary artery (Figure 3A). No cardiopulmonary bypass was available or required. The injury was repaired on the beating heart using an autologous pericardial patch secured with 4–0 polypropylene sutures reinforced with pledgets (Figure 3B). During repair, hemodynamics was supported with volume resuscitation, rapid coordination between anesthesia and surgery, gentle cardiac handling, and prompt evacuation of hemopericardium to relieve tamponade while maintaining visualization. Hemostasis was achieved, and chest closure was completed in the standard fashion.

Figure 3 (A) Intraoperative view of the right ventricular laceration. (B) Right ventricular laceration repaired with pericardial patch.

The postoperative course was uneventful. The patient recovered without documented arrhythmia, recurrent bleeding, or clinical heart failure, and was discharged on postoperative day 7 in stable condition. At 1-month follow-up, he remained asymptomatic, and chest radiography showed a normal cardiac silhouette without evidence of recurrent pericardial effusion (Figure 4). Longer-term echocardiographic follow-up was not available at the time of writing. See Table 1 (Timeline) for a summary of key events.

Table 1 Timeline Summary of Key Events

Figure 4 One-month follow-up chest X-ray with normal cardiac silhouette.

Discussion

This case adds to the growing literature on penetrating cardiac injury by illustrating that favourable outcomes can be achieved in a resource-limited environment through rapid ultrasound-guided diagnosis and decisive surgical intervention. Large series confirm that penetrating cardiac trauma is uncommon but carries very high prehospital mortality, with many patients dying before hospital arrival.¹ Outcomes for those who reach definitive care are influenced by the injured chamber and the presence of tamponade, with right-sided injuries and potentially “protective” tamponade associated with better survival when timely surgery is available.^2,6 Our adolescent patient presented several hours after injury with hypotension and echocardiographic evidence of tamponade, but survived following emergency sternotomy and beating-heart repair without cardiopulmonary bypass, underscoring the importance of time-critical decision-making in constrained settings.⁶

The explicit description of the resource-limited context is a key contribution of this report. Similar to other sub-Saharan centers, our institution lacks on-demand cardiopulmonary bypass for trauma, has restricted access to advanced imaging, and must prioritize blood products and intensive care resources.^5,6 Within these constraints, management relied on extended FAST and bedside transthoracic echocardiography, plain chest radiography, standard anesthetic monitoring, and conventional cardiac repair instruments. This approach is consistent with contemporary recommendations that emphasize early ultrasound as the primary diagnostic tool in suspected penetrating cardiac injury and support immediate surgical exploration when tamponade is identified in an unstable patient.^4,6 In such environments, delays introduced by additional cross-sectional imaging may be harmful, whereas prompt transfer to the operating room offers the only realistic opportunity for survival.^1,6

The choice between pericardiocentesis and immediate surgery remains an important management question. Modern trauma guidance regards surgical drainage and repair as the definitive treatment for traumatic cardiac tamponade, with pericardiocentesis reserved as a temporizing measure when operative access is delayed or when non-clotted effusion is suspected.^7,8 In our patient, echocardiography demonstrated echogenic clot within the pericardial space alongside hemodynamic instability, suggesting organized hemopericardium rather than free fluid. Under these circumstances, needle pericardiocentesis would likely have been inadequate and risked delaying definitive care. Emergency median sternotomy therefore provided both rapid decompression of tamponade and direct visualization of the right ventricular laceration, in line with evidence that early surgical evacuation and repair are associated with improved survival in traumatic pericardial tamponade.^3,7,8

The technical aspects of beating-heart repair near a major coronary vessel warrant emphasis, particularly in centers without cardiopulmonary bypass. Reviews of cardiac trauma repair highlight that success in this setting depends on meticulous surgical technique, careful cardiac manipulation, and close coordination with anesthesia to maintain preload and avoid hypotension during induction and sternotomy.^2,6 In our case, autologous pericardium secured with polypropylene sutures buttressed by pledgets provided a simple, widely available method to reinforce the friable ventricular edges, distribute suture tension, and reduce the risk of suture cut-through—an approach that is pragmatic for low-resource hospitals where access to synthetic patches or advanced hemostatic adjuncts may be limited.^2,6

Our experience aligns with other reports from resource-limited settings, which emphasize that adherence to core trauma principles—rapid transport, early recognition of tamponade, and immediate surgical control of bleeding—can offset some of the disadvantages posed by infrastructural constraints.^5,6 A recent case from another low-resource African centre described delayed presentation of penetrating cardiac injury successfully managed with pericardial drainage and subsequent sternotomy in a similar context, reinforcing the concept that organized, protocol-driven care can yield good outcomes despite limited technology.⁶ Compared with those reports, the present case contributes additional detail on hemodynamic management during beating-heart repair in an adolescent patient and on the integration of extended FAST into a streamlined decision pathway.

This report has limitations that are inherent to single-patient case studies. It cannot provide risk estimates or establish causal relationships, and our follow-up is restricted to the early postoperative period, without comprehensive long-term echocardiographic assessment for complications such as ventricular dysfunction, patch aneurysm, or constrictive pericarditis.^3,9 Nonetheless, detailed case descriptions remain valuable for clinicians in similar environments, because randomized data and large prospective series from low-resource settings are scarce. Future work should focus on prospective registries of penetrating cardiac trauma in low- and middle-income countries, standardized reporting of resource availability and delays to care, and evaluation of simplified algorithms that combine FAST with early sternotomy or thoracotomy for hemodynamically unstable patients.¹⁰

Conclusion

Penetrating cardiac injury with tamponade is a time-critical surgical emergency in which survival depends on rapid recognition and definitive hemorrhage control. In this adolescent patient, bedside ultrasound enabled early diagnosis and supported immediate sternotomy rather than temporizing pericardiocentesis, allowing successful beating-heart repair without cardiopulmonary bypass in a resource-limited Somali hospital. This case illustrates that, even where advanced imaging and cardiac bypass are unavailable, adherence to core trauma principles, early use of focused ultrasound, and prompt operative intervention can yield favourable outcomes in penetrating cardiac trauma.