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