A 46-year-old male patient was brought to the emergency department (ED) due to dyspnea secondary to a knife wound to the chest. According to the report of the paramedics who had transported the patient, upon first contact he had tachypnea of approx. 40 breaths per minute and a saturation of 80% without oxygen therapy. The large amount of blood in the patient’s surroundings, chest wound in the heart area and signs of shock spurred the paramedics’ “load and go” decision. Examination at the ED revealed: a Glasgow Coma Scale (GCS) of 14, heart rate 147 beats per minute, the blood pressure 88/60 mmHg, saturation with an oxygen mask an a 15 L/min flow rate – 90%, pale, clammy skin, pronounced respiratory effort with the involvement of accessory respiratory muscles. A 4-centimeter, heavily bleeding wound was identified below the left nipple, without features of subcutaneous emphysema. Symmetrical vesicular breath sounds above the lung fields, heart sounds were regular, with no murmur. Abdomen soft, not painful; post-thrombotic syndrome-type ulcerations on both calves, without edema. The patient denied any consumption of alcohol or substances of abuse. He denied suicidal ideation. Medical history was difficult to collect due to dyspnea and the patient’s severe restlessness and pain. The patient was unable to utter more than 1–2 words, kept removing the oxygen mask, claiming that he was unable to breathe through it. Blood was collected for laboratory testing. Morphine and lorazepam were administered intravenously (i.v.), leading to pain reduction and therefore calming the patient down, which enabled the placement of a mask on maximum oxygen flow rate. Bleeding was stopped by packing and compression. Lung ultrasound examination revealed normal sliding, no pneumothorax, free fluid in the pleural cavities nor tamponade were observed. Focused Assessment Sonography in Trauma (FAST) revealed no parenchymal organ injury. An ECG revealed sinus tachycardia approx. 140 bpm, right axis deviation, negative T waves in the V1–6 leads. The patient reported that severe thoracic pain had appeared several days earlier. A piercing-type discomfort on the left side of the chest was constant and intensified upon inspiration. The patient sought advice from the family doctor twice but he felt no improvement after taking the prescribed analgesics. The pain became so severe that it prevented free inspiration. Due to the pin-point location and the helplessness evoked by the lack of relief, he decided to thrust a knife where pain was most intense to alleviate the discomfort. He also reported that he had abused alcohol in the past and he had been sober for 2 years at the time. The reason for quitting his addiction was deep vein thrombosis of the lower extremity, diagnosed approx. 24 months earlier after several days of binge drinking. He reports that he took the prescribed medications for 3 months and as a result of the effective drug therapy and an almost 4-month period of alcohol abstinence, he discontinued anticoagulant therapy, regarding alcohol as the cause of thrombosis. He lived in the city center, alone, he was a widower, his wife died few years back because of breast cancer. A suspicion of pulmonary embolism was raised and a chest CT scan with contrast enhancement was ordered. A CT scan revealed a chest wound on the left side which did not penetrate into the pleural cavity. A massive embolism was identified in all segments of the right lung, with complete occlusion of arteries up to segment 8. Apart from that, thrombi were visible in the upper lobe segments of the left lung except the artery up to the 1st segment, left lower lobar artery completely devoid of contrast (Fig. 1,2).
The patient was transferred to the Cardiac Intensive Care Unit; considering the chest wound and risk of bleeding, a heparin infusion was initiated, taking into account the possibility of reverting its effects using protamine sulfate. Echocardiography was carried out, revealing an enlarged right ventricle, paradoxical septal motion with features of left ventricular overload. After 3 hours, BP dropped to 60/0 mmHg. The patient, whose condition was developing towards respiratory insufficiency, was urgently consulted by an anesthesiologist and a vascular surgeon. In condition of hipotension bleeding was so small that it allowed to freely find both ends of the bleeding vessels and bind it. Despite the chest wound, a multidisciplinar decision was made to administer fibrinolysis, which led in few minutes to a rapid improvement. No bleeding from the wound was observed. Oral vitamin K antagonist (VKA) and bridging therapy were initiated. Fever and dyspnea appeared on the 3rd day. A chest X-ray revealed lobar pneumonia, an empirical antibiotic was initiated. Proximal vein thrombosis of the left lower extremity was diagnosed during hospitlization. Due to the rapid improvement of the patient’s general condition and normalization of ECHO images the plan to implant a vena cava filter was abandoned. The patient was discharged on day 24 of hospitalization in a good general condition, with a properly healing chest wound. During follow-up at the Cardiology Outpatient Clinic after 3 months, an exercise test and echocardiography were carried out, revealing no abnormalities. The patient took the medications and monitored INR values very systematically; all measurements during the 3 months were within the recommended limits, the patient remained sober. Until discharge, as well as during subsequent follow-up visits, no local complications of bleeding vessel ligation were observed.