Injuries of the Heart and Great Vessels Due to Pins and Needles

Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from Thorax (1969), 24, 246.

Injuries of the heart and great vessels due to pins and needles

DAVID CHAS. SCHECHTER' AND LAWRENCE GILBERT From the Section of Cardiothoracic Surgery, Newark Beth Israel Hospital, Newark, N.J., U.S.A.

Three instances of cardiac injury from needles in two adults are described. Trauma was accidental in one and due to suicidal attempts in the other two. The objects were removed. There are 157 published accounts of wounding of the heart and/or great vessels by pins and needles. The victims have ranged from infants to the elderly. Causative agencies were accidents, suicide, and homicide. A few were discovered at necropsy in presumably asymptomatic persons. Six of the accidental injuries were iatrogenic. The objects reached the heart or great vessels from trans- thoracic insertion, ingestion, embolization, aspiration, or transabdominal penetration. The overall mortality incidence was about 50%. Acute cardiac tamponade was the dominant cause of death. Almost all individuals survived who were operated upon and from whom the object was removed. The right ventricle was hurt most often, but no region of the heart or of the great vessels was spared. Occasionally multiple parts were affected. The primary damage occurred principally while the foreign body was extracardiac and relatively immobilized, from repetitive

scratching or puncturing of the beating heart. Chest pain and unfolding patterns of tamponade copyright. were inconsistent in onset, severity, and duration. Death ensuing days or weeks after the initial injury was frequent. Progressive haemopericardium in somne cases was due to or aggravated by laceration of a structure from within outward. Late complications-several fatal-were consequent upon inflammation, sepsis or thromboembolism. It is urged that all foreign bodies in

the heart or great vessels be retrieved, even if seemingly innocuous clinically. http://thorax.bmj.com/

'One discovers the heart under the unexpected aspect cannula, a false tooth, a straw from a broom, and of a bric-a-brac shop, where may be found objects as a worm (Blaiha, 1935; Decker, 1939; Barrett, disparate as in the fabled stomach of the ostrich.' Dr. Chas. Esmein (1910) 1950; Lowen, Fink, and Helpem, 1950; Bajardi, 1953; Tinzer, 1953; Farber and Craig, 1956; Cardiac wounding by foreign bodies poses prob- Parmley, Mattingly, and Manion, 1958; Weekley lems in management that are dissimilar from those and Maltby, 1963 ; Gajdas, 1963; Leonard and

of other pathological conditions. That the heart Gifford, 1965; Hudson, 1965). on September 27, 2021 by guest. Protected or great vessels may be severely damaged by Over the past decade numerous accounts have objects of unimpressive size or appearance is a been published of iatrogenic mishaps resulting in fact. In the main, preoccupation with this variety pieces of diverse medical paraphernalia being of injury has pertained to bullets, shrapnel, and swept into the heart or great vessels. Disconcerting kindred projectiles. However, similar trauma has situations have arisen from the breakage and loss also occurred in consequence of strikingly diversi- into the blood stream of venoclysis tubing, fied items. A pot-pourri of objects has been in- Pudenz-Holter valves for decompression in hydro- culpated: the spine of a sting fish, metallic cephalus, and flexible steel stylets used durinig splinters, tooth picks, dental plates, fish bones, cardiac catheterization (Lillehei, Bonnabeau, and pieces of ice-pick blades, bone spicules or Grossling, 1965). sequestra, scraps or rods of wood, glass slivers, an aluminium pipe stem, thorns, stud gun nails, metal Wounds of the heart and great vessels due to files, drill fragments, fruit pips, vegetable fibres, an pins and needles are not common: nor are they orthopaedic wire strut, a rubber catheter, a metal harmless. This communication reports a personal 'Present address: Section of Cardiovascular and Thoracic Surgery, experience with three instances of sewing needle New York Medical College, New York, N.Y. injuries to the heart in two patients. 246 Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from Injuries of the heart and great vessels due to pins and needles 247

CASE REPORTS an area of recent ecchymosis was seen; and soon, after dissection and search, about 1 mm. of the needle CASE 1 hub was found projecting free of the adherent peri- First admission B. B., a 29-year-old woman, was first cardium. The needle was easily withdrawn. There seen by one of us (L. G.) in December 1960 at her was no bleeding from the puncture site. Exploration psychiatrist's consulting-room. On the preceding of the subcutaneous tissue exposed the 'old' needle evening, while sitting, she had partly pushed an fragment sequestered there. Probing in the costo- ordinary sewing needle into the front of her left phrenic sulcus, hampered by considerable adhesions, chest. The pain made her stand up, and with this did not reveal the needle anticipated in this area. As sudden movement the remainder of the needle dis- it was considered to be harmless, no further attempts appeared beneath the skin. The pain was relieved were made to retrieve it. when she lay down in the prone position. The patient's recovery was uncomplicated, and she There was a minute fresh puncture site in the 5th was discharged on the eighth postoperative day to intercostal space just left of the sternum. Fluoroscopy another institution for psychiatric treatment. showed the needle to be entirely within the cardiac silhouette and moving synchronously with each beat. CASE 2 J. U., a 43-year-old roofer in the habit of The deepest portion of the needle moved more carrying a needle in his left shirt pocket for removing vigorously than its superficial parts. splinters from his fingers. was knocked on the chest Operation was performed approximately 18 hours by a ladder. Sharp pain was experienced over the left after injury. Thoracotomy was through a sub- breast, but this grew less within an hour, and he was mammary 5th intercostal incision. The hub of the able to resume work with no further discomfort. He needle was palpated at a small ecchymotic area in noticed a speck of clotted blood on his undershirt the pericardial fat over the right ventricle. On dis- and was aware of the loss of his needle, but was secting the fat a glint of metal was perceived. The unconcerned about this until three days later, when needle was found still projecting through the peri- again he received a glancing blow on the chest, this cardium. It was grasped with a haemostat and with- time from a swinging door. Pain ensued and persisted. drawn gently. Oozing of dark blood through the It was sharp, localized to the left breast, and not and the latter altered by position or breathing. wound in the pericardium followed, copyright. was opened widely anterior to the phrenic nerve. Physical examination was normal; but a hard, Approximately 50 ml. of blood was aspirated. The tender, subcutaneous nodule, 0 75 cm. in size, was pericardial sac was left open. palpable in the 5th intercostal space immediately The patient's recovery was uncomplicated. Radio- lateral to the left of the sternum. The electrocardio- logical studies on the seventh postoperative day gram was normal. showed a normal cardiac silhouette, no haemothorax, Radiography revealed a linear density in the region http://thorax.bmj.com/ and no other foreign bodies in the chest wall or of the cardiac ventricular septum, its outer end cavity. On this same day the patient was transferred directed towards the anterior chest wall, 4 cm. from to an institution for psychiatric care. the skin. By fluoroscopy the free end of the needle One week later the patient's physician announced was seen to vibrate synchronously with the heart that chest radiographs taken that day had disclosed beat. two foreign bodies. These films revealed a sewing Operation was undertaken about eight hours after needle located in the lateral lung field, possibly in admission. A left 5th intercostal anterolateral incision the costophrenic sinus. A second, partially curved, was made and subsequently extended to the right. broken needle was deep in the subcutaneous tissue, transsternally, without entering the right pleural anterior to the sternum. The consensus was to leave cavity. No track was visible in the intercostal tissues on September 27, 2021 by guest. Protected these objects in place. or on the surface of the pericardium. Nor was there any imprint on the heart itself to indicate the entry Second admission In December 1965, B. B. (now 34 of the needle. The pericardial sac contained less than years of age) was referred directly from the psychi- 50 ml. of blood. atrist's consulting-room after remarking that she had Methodical palpation and pressure on different plunged a needle into her chest five days previously parts of the heart failed to uncover the site of nida- during a fit of mental depression. Radiography and tion of the needle. Recourse to an electromagnetic ffiluoroscopic examination showed the needle entirely locator was not fruitful, and neither was probing of within the cardiac silhouette and moving synchro- the right ventricular chamber with a haemostat nously with each beat. In addition, the presence of inserted through its apex. two other foreign bodies, noted in the radiographs A finger was introduced into the right atrium, taken five years previously, was confirmed. Neither through the appendage, and about 1 cm. of the point of these foreign bodies had migrated. of the needle was felt immediately above the medial That same evening the left thorax was re-explored cusp of the tricuspid valve. By combined pressure through the former incision. The pericardium was on the needle and quickly flattening the heart in the densely fused to both the heart and retrosternal anteroposterior plane by manual pressure it was tissues. Over the anterior surface of the right ventricle, possible to extrude the heel of the needle through Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from 248 David Chas. Schechter and Lawrence Gilbert the anterior cardiac wall and to grasp it with a haemo- was discovered in a heart at necropsy. Five cases stat and remove it. The pericardial sac was left open. were due to thoracentesis or to hypodermic needles There were no arrhythmias. The patient withstood breaking at the hub. One involved embolism of the procedure well, and there were no untoward a radium needle from the skin to the pulmonary postoperative sequelae from the manipulations described. artery. The rest of the injuries were caused by assorted ANALYSIS OF THE WORLD LITERATURE pins. The shortest which resulted in death was less than 2 cm. long; the longest was an 8-in. hatpin. Cardciac injuries from pins are almost identical There were also a shawl pin, a brooch pin, two with those from needles. Some 157 cases of hairpins, and four safety pins. Multiple pins were wounds caused by these objects have been col- used for suicidal purposes in two instances, by lected up to 1967. They, together with those we being swallowed or thrust into the body. A blunt have described, comprise the context of our re- 'bobby pin' was ingested accidentally and came view. Recitals of the 'modes of injury, as well as to rest in the heart in one case. their nature, furnish rather provocative reading matter. CAUSATION The pins and needles entered the heart muscle or its cavities chiefly by transthoracic pene- HISTORICAL The earliest documentation on this tration or by ingestion. In 88 authenticated cases subject was made in 1600 by Paulus Zacchias, the the injury was accidental. The transthoracic route father of forensic medicine. A priest decided on accounted for 68 of these, the invariable mechan- immolation by castrating himself and thrusting ism being a fall, a blow or an embrace, with the several stout needles into his body, including one object stuck originally in the victim's or someone through the heart. He survived for six days. else's clothes. In one instance a man nearly died of a barmaid with Zacchias was duly impressed by this-'. .. hic when a needle in the bodice his est . whom he was engaged in coitus traversed chest quidem mirabile auditu .'-for had not copyright. Aristotle himself stated that touching the heart wall. Six of the accidents were iatrogen.ic. The brought about instantaneous death ? In 1782, a loss of a radium needle on that basis has pre- Sardinian nobleman, at the court of King viously been cited. The others were from break- Amadeos, was slain during sleep by his exasperated age of a needle during thoracentesis, intracardiac wife. She plunged into his heart a needle which injection, and intravascular embolization during http://thorax.bmj.com/ was made of gold. Admiral Pierre Charles Jean- performance of venoclysis. In one child, the needle Baptiste Silvestre, the Duke of Villeneuve, being entered the thorax across the abdominal wall, and responsible for tactical blunders at the Battles of only in a single case was it aspirated. In the the Nile and Trafalgar, fell into disfavour with remainder, the object was swallowed. Napoleon. Despondent, he purchased anatomical There were 52 injuries consequent on suicide or plates to become acquainted with the arrangeiment suicidal design. All but seven, in which the objects of the thoracic viscera. Then, with precision, he were swallowed, were transthoracic wounds. In passed a needle into his heart. He survived several some of these there were concomitant self-destruc- as insertion of into the years and was captured by the English on 22 April tive actions, such glass on September 27, 2021 by guest. Protected 1806. vagina, amputation of genitalia, slashing the throat It is surprising, considering the antiquity of with a razor, drinking laudanum, and cutting the cardiac acupuncture and its widespread use even wrist. One woman swallowed an entire packet of in eastern European countries during the cholera needles. Another, to avoid drawing attention, epidemics of the last century, that only a single feigned prayer, meanwhile surreptitiously pressing death is on record from this type of injury (Schiff, 30 pins and needles into her chest with a Bible, 1965). until haemiorrhage from the superior vena cava ended her life. One woman both swallowed needles OBJECTS There are reports of 147 injuries from and thrust several more into diverse parts of her needles. Most were from plain household sewing body. or darning needles. In nine instances, two or more Pins and needles were used as weapons for needles were used. In four, knitting needles of murder on five occasions. The most macabre inci- various lengths were incriminated. In one, a 9-cm. dent concerned a neonate who was mutilated needle for mending sails was used in a suicide almost beyond recognition by being stabbed 20 attempt. The shortest needle resulting in a fatality times with a knitting needle and 40 times with a was less than 2 cm. long. A gramophone needle pen-knife. Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from Injuries of the heart and great vessels due to pins and needles 249

In six cases, the object was discovered fortui- beat. Cessation of this movement was usually an tously at necropsy. The mechanism of injury was ominous sign, inferring that relay of the cardiac not identified in the last nine. pulsations was stilled because of an interposed enlarging mass of blood. A cardiac murmur or AGE AND SEX There were 76 males and 60 females pericardial friction rub was audible in a few in the series. The sex of the other 24 was not patients. stated. The youngest victim was the infant just Incidental symptoms such as retching, vomiting, mentioned; two patients, the oldest, were 82 years weakness, cough, and syncope were ordinarily of age. nonspecific accompaniments of trauma. Fever, As might be anticipated, all the infants and sweats, and tachycardia usually indicated suppura- children were hurt accidentally, either in a fall or tive pericarditis, carditis or pleuritis. by being clasped against the bosom of a mother Diagnosis was difficult in many of the infants or nurse whose frock contained the object. About and children, especially when information about 45 of the accidental injuries took place in persons trauma was vague or wanting. Several displayed over the age of 20 years, the oldest being 82 years. unexplained lassitude, restlessness or anorexia. The proportion of accidents in males was 43 to Others were given to recrudescent syncope or con- 35 in females. The sex of the remaining 10 acci- vulsions. A few showed cardiac decompensation. dent victims was not stated. In both adults and the young, ingravescence or In the suicidal group of 52 cases, the youngest dissolution followed an abrupt pattern, with was a 17-year-old adolescent, and the oldest was sudden death or a rapid sequence of heart failure, 82 years of age. There were 25 men and 22 jugular venous distension, shock, and coma pre- women. The sex of the five others was not stated. saging death from acute cardiac tamponade. This took place both early and late after injury. PHYSICAL SIGNS The quality, onset, duration, and DIAGNOSIS Immediate death has been uncommon. temporal relationship of the symptoms varied In most, the correct diagnosis was made, or was widely. The most consistent was precordial or at least attainable, within a few hours from the copyright. retrosternal pain. This was sharp, lancinating or precipitating trauma. On 10 occasions it was ob- dull. It was clamant uniformly at the start, be- vious, the article being seen transfixing the skin. coming degravescent after irregular periods, and In 14 others, the object was subcutaneous, and often recurring with different qualitative charac- palpable, usually with transmitted cardiac pulsa- teristics as a terminal event. Deep-seated pain and tions. http://thorax.bmj.com/ occasionally dysphagia were early but temporary When information about injury was volunteered manifestations of swallowed foreign bodies. The by the patient or by an interested party, leading type of secondary pain arising after a relatively to speedy medical evaluation, the chief diagnostic symptom-free interval, and described as an aid was radiology. The shadow cast by a needle 'angoisse' or oppressive in intensity, is recognizable was unmistakable, and its intimate relationship to as characteristic of cardiac compression from the heart was corroborated by its oscillations being haemopericardium. The severity of the initial pain visualized with fluoroscopy. Cardiac arrhythmias was greater when the object was stil extracardiac, were rare, save as a terminal event; electrocardio- as in the pericardium or soft tissues of the chest graphy was generally not helpful except to cor- on September 27, 2021 by guest. Protected wall. The pain usually disappeared after complete roborate clinical suspicion of cardiac tamponade entry of the object into the heart. or pericarditis. Dyspnoea preponderated next. It usually devel- Diagnostic perplexities were presented by those oped later and in association with increasing peri- infants regarding whom there was no foreknow- cardial effusion. When it was pronounced, a sense ledge of injury. The customary picture in these of suffocation was complained of. Palpitations cases was one of mystifying physical deteriora- were rare. tion lasting for days or weeks, culminating in Very early, the foreign bodies were either visible frank cardiac tamponade. Often, without ante- or palpable in the skin, depending on the force cedent clinical portents, children became gravely with which they had been driven in. Needles either il and were admitted to hospital, after which an left no trace of puncture on the skin or a small intracardiac foreign body was discovered by area of ecchymosis. The ingress of pins was radiography. ordinarily halted by their broadened end, but this Two people, a young boy and a middle-aged was inconsistent. When there was a subcutaneous woman, insisted that they had a needle in the protrusion, it throbbed rhythmically with the heart heart; neither was believed and both died. Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from 250 David Chas. Schechter and Lawrence Gilbert MANAGEMENT The object was removed with the Not infrequently, the foreign body caused fingers nine times out of the 10 that it jutted above damage by wounding adjacent structures, either the skin. In one case a needle broke when a child by perforating them individually in transit or by tried to take it out, and in another, the manipula- impaling them concomitantly 'en brochette'. tion resulted in its being pushed further into the chest, necessitating thoracotomy. Death occurred FATE Apart from the cases discovered coinci- in three of the cases when the object was pulled dentally at necropsy, and those patients who died out with the fingers. from unrelated or intercurrent disease, the mor- tality in the series was 85 cases, or roughly 50%. The foreign body was subcutaneous in 14 cases, Thirteen of the 85 deaths followed some form once with an attached cotton thread trailing over of major surgical intervention. Infection was the skin. In 11 of these, the object was removed responsible for three, iatrogenic errors for two, after incising the skin over it. In three others acute tamponade for three, the moribund state of these manceuvres were unsuccessful, and major the patients at operation for four, and an inade- operation followed. One patient died after quate procedure for one. Closer scrutiny of the removal of the object from the subcutaneous causes of these deaths disclosed that, except as tissues. regards the individuals who were operated upon Mediastinotomy, pericardiotomy, or formal while desperately ill, all the fatalities could have thoracotomy, each of varying magnitude, was been prevented. Thus, one of the iatrogenic mis- undertaken 53 times, and extraction by oesophago- chances consisted of laceration of a coronary ves- scopy once. Six of these operations failed, the sel. In none of the three who developed tamponade foreign body being left behind. Four other had drainage of the pericardium been effected, patients in whom emergency thoracotomy was the surgeons being lulled into false security by the undertaken died on the operating table or soon absence of demonstrable haemopericardium when after. the object was removed.

In three cases, the object was extruded spon- The foreign body was taken out by somecopyright. taneously by the heart. In one, it appeared after surgical means, major or minor, in 51 of the 56 10 days beneath the ensiform cartilage, and in a survivors, and left in the heart in five. Of the second, at a superior intercostal space after three latter, two died from unrelated ailments after 18 weeks. Both were simply removed by incising the months, the third was reported to be in good skin over them. In the third, a needle which had health a few years later, the fourth was barelyhttp://thorax.bmj.com/ travelled from the antecubital vein to the left lung salvaged after incurring empyema and suppura- via the ipsilateral pulmonary artery over a period tive pericarditis, and in the last the needle was of eight years was removed by wedge resection extruded eventually from the heart. Another per- of the lung. son, from whom a needle was withdrawn but the pericardium was sutured, suffered in the post- FINDINGS AT OPERATION OR NECROPSY The affecte-d operative period from pleuritis, pericarditis, anatomical structures were distributed thus: cardiac arrhythmias, and spontaneous drainage through the wound of bloody pericardial fluid.

Right ventricle 66 Left ventricle 47 on September 27, 2021 by guest. Protected Haemopericardium 46 Oesophagus 4 DISCUSSION Focal or diffuse pericarditis 20 Stomach 4 Foreign bodies may reach the heart by any of the Ventricular septum 16 Tricuspid valve 3 following pathways: through the chest wall- Right atrium 12 Pulmonary artery 4 directly through the sternum, ribs, or an inter- Lung 11 Aorta 4 space, or indirectly after traversing the pleural Intracavitary cavity and/or lung; across the oesophagus or from thrombus 8 Haemothorax 4 the duodenum into the vena cava; across the dia- Left atrium 7 Mitral valve 3 phragm, from the abdominal wall or the peri- Both ventricles 7 Superior vena cava 2 toneal cavity; across the respiratory tract; or by Papillary muscles 7 Pulmonary infarction 2 transport in the bloodstream from a distant region. Diaphragm 6 Bronchus 2 The commonest route is through the chest wall. Pleuritis 6 Vertebrae 2 Sundry aspects of injuries from pins and needles Coronary vessels 6 Inferior vena cava 1 distinguish them from other varieties of cardiac Mediastinitis or media- trauma. The principal distinction concerns their stinal haematoma 5 Liver 1 dimensions and configuration, the significance of Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from Injuries of the heart and great vessels due to pins and needles 251 which was apparently appreciated a few centuries great impact, it is more likely to be forced into ago. During the scientific renaissance, many people the heart at once, so that the phase of scratching disproved Aristotle's dictum about cardiac inviol- or cutting of the cardiac surface is circumvented ability by sticking pins and needles into the hearts and haemopericardium is minimal or absent. In of animals. They demonstrated that such wounding fact, such trauma seems to be associated with a was reimarkably well tolerated and compatible more favourable outcome. This remarkable pro- with life. Moreover, exsanguination did not hap- cess has been noticed on several occasions, espe- pen, as had been supposed, except when less cially when the object possesses free mobility. In fleshly, non-sealing portions of the heart were some instances the steadily forward course into pricked. These trials were made directly on the the heart has been visualized by means of success- organ, and it was not until much later, when sive radiographs. In others, needles have been seen clinical accounts were published, that notable to move or have disappeared from sight prior to differences from the experimental setting became or at operation because of vigorous contractions evident. Paradoxically, the most obvious of these of the heart. In one case the advance of a pin differences has not been em,phasized in the litera- through the heart wal was followed on serial ture. It concerns the fact that the heart is more radiographs until the head of the object halted its vulnerable to serious injury while the foreign body further transit. is extracardiac than when it is intracardiac. It is noteworthy that the progress of haemoperi- It is clear that the major damage is caused when cardium has been unpredictable, numerous the object is partially immobilized-in the thoracic patients dying many days or weeks after the trau- parietes, for example. Then, repetitive wounding matic incident. Necropsy descriptions make it results from the unceasing motion of the heart probable that some of these late deaths from tam- against the sharp point of the fixed foreign body. ponade have been from a secondary haemoperi- The danger to life of rigidly held objects is exhi- cardium subsequent to realignment of the object, bited in the cases surveyed. Quite often the hearts accompanied by grazing or laceration of the heart have borne marks denoting continuous punctur- from within outward. The evolution of this pheno- copyright. ing, scraping in saw-tooth pattern, or slicing along menon depends in large part on the axis of a semilunar or elliptical arc. Intact pins have been entrance of the object and where inside the heart prime offenders in this connexion, since their chambers it becomes situated. For instance, if a broadened end has ordinarily restrained free pas- needle becomes embedded in a straight line in the sage into the thorax. In one particullarly striking ventricular septum, further travel would tend to be http://thorax.bmj.com/ case, the heart shredded itself against a brooch-pin impeded. Conversly, were it not thus stabilized, rendered immovable by an ornate handle. Of but floated loose in the left atrium, it would be course, the longer the foreign body, the less likely more likely to migrate, as do needles and pins in is this mechanism to become operative, but then other parts of the body where there is much the greater are the risks of simultaneous skewering movement. In -the series there are only three of several portions of the heart. This is especially examples of a needle being extruded by the heart true in younger subjects, in whom the easy com- back into the pleural cavity, and thence to between the ribs. pressibility and small size of the chest magnify on September 27, 2021 by guest. Protected the importance of even a 2-cm. needle. Needles which become fixed in the substance of The next feature of interest regarding this cate- the heart may remain clinically harmless for a long gory of foreign body is that the sleek and narrow time, as attested by their having been found inci- contour allows fairly swift migration into the dentally at necropsy. The longest asymptomatic heart. Because of incessant movements of the rib interval has been 37 years. These are exceptional cage and cardiac contractions, needles and frac- situations, however. The inflammatory reaction tured pins caught by one end in the myocardium provoked after the object has been encompassed do not remain stationary in the soft tissues for eventually results in its becoming 'encysted'. On long. They are pulled gradually, but inexorably, the other hand, this walling-off may be hindered into the substance of the heart. By then the bulk by infection or by thrombosis. That a silent of the damage has been done. Haemopericardium foreign body need not necessarily signify benign is the principle cause of complication and death, encapsulation is exemplified by a multiplicity of and is due mainly to rents on the surface of the complications arising at a remote period after the heart rather than to the slender, self-obliterating initial trauma. path left by the object as it passes through the Both focal pericarditis and chronic constrictive wall of the heart. If the object is delivered with pericarditis have been described from weeks to Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from 252 David Chas. Schechter and Lawrence Gilbert years following injury. At times they have ended Deliberate drainage of the pericardial sac, in death. Often se.psis has featured prominently regardless of the presence or absence of haemo- as the agency of morbidity or in hastening the pericardium, should be accomplished always. patient's death. Clot has frequently been found Failure to do so, or tight re-suture of the peri- attached to parts of pins and needles exposed to cardium, has been accompanied at times by the intracardiac blood currents. Death has ensued in reaccumulation of pericardial fluid. In the same some patients from embolization of fragments of context, even if a pin or needle is amenable to such thrombi, especially the suppurative ones. A simple removal, i.e., digitally or by incising the few of the objects have even become rusty or skin over it, the physician is not relieved of re- corroded from contact with blood. sponsibility for protracted management of the case. Rather, the patient should be admitted to TREATMENT The outcome of cardiac injuries due hospital and kept under physical and radiological to pins and needles has been characterized in the surveillance to forestall cardiac tamponade from past by a high mortality, which should serve as a delayed bleeding. In a not inconsiderable number warning against any misconception that these of cases, the insidious progression of haemo- foreign bodies are innocuous. Death in most cases pericardium after the aforementioned simple has been due to cardiac tamponade. manoeuvres, or fresh haemopericardium due to There is little quibbling about the necessity for other unsuspected foreign bodies, have been over- prompt surgical intervention when an intracardiac looked with fatal consequences. foreign body of any sort produces symptoms or Whereas there is no equivocation about the menaces life. Emergencies from pin and needle urgency for operating in acute symptomatic injuries are predominantly instigated by cardiac phases olf cardiac wounding by foreign bodies, tamponade. Pericardiocentesis is permissible- doubts exist in some quarters regarding proper indeed, probably desirable-as a prelude to an criteria for surgically 'molesting' chronic intra- operation intended to retrieve the foreign body cardiac foreign bodies. There is no denying that and repair whatever damage it has inflicted when some pins and needles of long standing in thecopyright. haemopericardium is present. Undue temporizing heart may not cause any demonstrable harm. But in such situations is ill-advised, for, as a number these are medical curiosities. The dangers of late of the reviewed cases have 'shown, death may embolic, inflammatory, and septic sequelae from follow quite quickly on the heels of demonstrable retained pins and needles are real, and transcend

haemopericardium. Precise radiographic localiza- the risks from striving for surgical retrieval ofhttp://thorax.bmj.com/ tion of the foreign body is desirable but is not these objects. While acknowledging that general- essena.al. This information can be secured by izations in medicine are incautious, we neverthe- films taken while the patient is in the operating less wish to express our conviction that all room, with all necessary equipment at hand in intracardiac foreign bodies should be removed, the event of precipitous deterioration in his con- even if silent clinically. That is surely a reasonable dition. Moreover, it sometimes happens that the course to adopt, for not only does it effectively object will have migrated by the time operation is safeguard against the eventuality of organic begun. Once the foreign body has been identified disease, but it also dispels uneasiness or other on admission to hospital, the goal should be to emotional stress which the patient is likely to on September 27, 2021 by guest. Protected rermove it as soon as possible without delays have about being the bearer of a potentially deadly entailed by additional non-contributory studies. object in the heart. Pericardiotomy should suffice in most instances for evacuating the haemopericardium, withdraw- REFERENCES ing the object, and performing cardiorrhaphy. The Bajardi, F. (1953). Ueber einen Fall von Pflanzenzellembolien im exposure must be adequate since unsuccessful Koronargefasssystem. Wien. klin. Wschr., 65, 815. Barrett, N. R. (1950). Foreign bodies in the cardiovascular system. operations in the series have been associated with Brit. J. Surg., 37, 416. inadequate procedures or limited manceuvrability Blaha, J. (1935). Embolische Verschleppung eines Fremdkorpers (Gummikatheter) ins Herz bei einem kriminellen Abortus. Zbl. through 'key-hole' incisions. It is immaterial Gynuk., 59, 746. whether a vertical sternotomy or an anterolateral Decker, H. R. (1939). Foreign bodies in the heart and pericardium- should they be removed? J. thorac. Surg., 9, 62. thoracotomy approach is selected, providing there Farber, S., and Craig, J. M. (1956). Clinical Pathological Conference, is unhampered accessibility to all regions of the Children's Medical Center, Boston, Mass. J. Pediat., 49, 330. Gajdas, J. (1963). Rib fracture in a 4-year-old child with perforation heart and great vessels. Ancillary aids, such as of the lung and right cardiac atrium by an ossal sequester. Pat. electromagnetic localizers, have not been useful pol., 14, 521. (In Polish: English summary.) Hudson, R. E. B. (1965). Cardiovascular Pathology, Vol. 2, p. 1611. in these cases. Arnold, London. Thorax: first published as 10.1136/thx.24.2.246 on 1 March 1969. Downloaded from Injuries of the heart and great vessels due to pins and needles 253

Leonard, J. W., and Gifford, R. W., Jr. (1965). Migration of a Kirsch- Parmley, L. F., Mattingly, T. W., and Manion, W. C. (1958). Pene- ner wire from the clavicle into the pulmonary artery. Amer. J. trating wounds of the heart and aorta. Ibid., 17, 953. Cardiol., 16, 598. Schiff, A. F. (1965). A fatality due to acupuncture. Med. Tms (N. Y.), Lillehei, C. W., Bonnabeau, R. C., Jr., and Grossling, S. (1965). 93, 630. Removal of iatrogenic foreign bodies within cardiac chambers Tanzer, A. (1953). Intrakardiale abgebrochene Injektionskanule. and great vessels. Circulation, 32, 782. Fortschr. Rontgenstr., 78, 357. Lowen, H. J., Fink, S. A., and Helpern, M. (1950). Transfixion of the Weekley, A. S., Jr., and Maltby, G. L. (1963). More stud-gun injuries heart by embedded ice pick blade with 8 months' survival. Ibid.. (letters). New Engi. J. Med., 269, 110, 111. 2,426. Zacchias, P. (1600). Quaestiones medico-legales, I (5), 375. copyright. http://thorax.bmj.com/ on September 27, 2021 by guest. Protected