Ann Thorac Surg 2001;72:2106-2107
© 2001 The Society of Thoracic Surgeons
Case report
Major mediastinal injury from crossbow bolt
Santiago A. Endara, MD*a,
Antonio A. Xabregas, FRACSa,
Christopher S. Butler, FANZCAb,
Mark J.E. Zonta, MBBSa,
John Avramovic, FRACSc
a Department of Cardiothoracic Surgery, Townsville General Hospital, Townsville, Queensland, Australia
b Department of Anesthesia and Intensive Care, Townsville General Hospital, Townsville, Queensland, Australia
c Department of General Surgery, Townsville General Hospital, Townsville, Queensland, Australia
Accepted for publication December 13, 2000.
* Address reprint requests to Dr Endara, Department of Cardiothoracic Surgery, Townsville General Hospital, Eyre St, North Ward, Townsville, Queensland, 4810, Australia
e-mail: santiago_endara{at}health.qld.gov.au
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Abstract
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We treated a 26-year-old male who sustained a self-inflicted injury to the mediastinum with a crossbow bolt. Injuries involved penetration of the sternum 1 cm below the sternomanubrial joint, right lung, pericardium, ascending aorta, right pulmonary artery, esophagus, and azygos vein. He was treated successfully with cardiopulmonary bypass and hypothermia. Exposure was achieved with a combination of a sternotomy and right thoracotomy.
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Introduction
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Penetrating thoracic trauma is increasing in frequency due to the easier availability of firearms, but crossbow bolt injuries are uncommon. The tendency of the crossbow bolt to remain in situ appears to limit catastrophic hemorrhage despite involving major vessels. This means that these patients may present to hospital alive and require surgical management. We report a case of a 26-year-old man who survived such an injury.
A young man presented to an outback hospital with a crossbow bolt penetrating his sternum at the level of the second intercostal space (Fig 1). Examination revealed hemodynamic stability, distended neck veins, and a Glasgow Coma Scale score of 15. Chest radiographs showed the location of the missile (Fig 2).
The 554-mile transfer to our hospital by aircraft accounted for a 7-hour delay from time of injury until presentation to the operating room. On arrival he remained hemodynamically stable. No further investigations were obtained. The bolt was undisturbed.
In the operating room, after anesthetic induction, a double-lumen endotracheal tube was placed. The left femoral vessels were exposed, and a right anterior thoracotomy was done through the second intercostal space to visualize the trajectory of the bolt. Once penetration of the pericardium was noted, heparin was administered. Cardiopulmonary bypass was instituted with left femoral arteriovenous cannulation. A wedge of right upper lobe pierced by the bolt was resected with a stapler. A small square piece of sternum was excised encompassing the shaft of the bolt at its entry site, followed by a median sternotomy. This enabled retraction of the sternum while maintaining manual fixation of the bolt. The pericardium was opened releasing a hemopericardium. Hemorrhage from the entry site into the ascending aorta was encountered and initially controlled with digital compression. A purse string suture around the bolt established hemostasis. Because of the location of the aortic injury, penetration of the right pulmonary artery was suspected. A single-stage venous cannula was placed in the superior vena cava, and umbilical tapes were snugged around both vena cavae.
With cross-clamping of the aorta and administration of retrograde cardioplegia, cardiac arrest was achieved, and hypothermia to 28°C established. The aorta was transected from the anterior to the posterior shaft of the bolt, so as to follow its trajectory and to identify the right pulmonary artery. This was similarly transected to further identify the missile trajectory. Thrombus was found in the right pulmonary artery lumen and was removed. With exposure of the posterior mediastinum, the bolt was retrieved and the injury to the esophagus identified. Despite difficult exposure, bleeding on the anterior wall of the esophagus was controlled. Esophagoscopy showed injuries to both anterior and posterior esophageal walls. The right pulmonary artery and aorta were then individually repaired with end-to-end anastomoses, the patient rewarmed, air removed from the heart, and the cross-clamp removed. After weaning from cardiopulmonary bypass and repair of the femoral vessels, the sternotomy and anterior thoracotomy were closed and the patient placed in the left lateral position. A right posterolateral thoracotomy was then done, and the pleural cavity was entered through the fifth intercostal space. The azygos vein was bleeding and was repaired. The esophagus was then exposed and both walls repaired. The suture lines were reinforced with a pedicle of intercostal muscle, pleural drains were placed, and the thoracotomy closed. The patient was then taken to the intensive care unit in stable condition. Twelve hours later pulses were noted to be absent in the right foot. Exploration and embolectomy of his right leg vessels resulted in retrieval of an embolus. Fasciotomies were done in the lower leg at the time of embolectomy.
After a prolonged intensive care unit stay, the patient was transferred to the ward.
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Comment
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Thoracic great vessels are injured in about 4% of penetrating chest trauma cases. These injuries are increasing in frequency and carry a mortality rate higher than 90% [1]. Aortic injuries have potential for greater intraoperative hemorrhage and are more difficult to control than injuries to the aortic arch branches [2]. The crossbow is a rare cause of penetrating injury to the chest, with few cases reported [3].
This case is exceptional in that multiple mediastinal structures were involved, yet the patient survived both prolonged transfer to our hospital and surgical repair. We believe this was due to the unusual nature of the missile. It remained intact, was well stabilized by its entry point and although it traversed vital structures, the tissues were in close apposition to its entry and exit points. This limited hemorrhage in an injury that should otherwise have resulted in rapid exsanguination. The missile concerned has a velocity of 65 m/s [3] and causes minimal tissue damage outside the line of trajectory, in contrast to high-velocity projectiles where tissue cavitation occurs.
Mild cardiac tamponade was evident at the peripheral hospital, so the patient was transferred without intubation because of the risk of cardiovascular compromise occurring with positive pressure ventilation. Although this involved a high-risk transfer, it was less hazardous than exploration of the wound without access to cardiopulmonary bypass.
Preoperative imaging to delineate the extent of injury in stable patients has been suggested [1, 4]. Imaging was not done as cardiac tamponade was evident and although the patient was hemodynamically stable, wound exploration was indicated. In view of the high probability of cardiac or major vascular injury, the urgent need for cardiopulmonary bypass was likely, and the femoral vessels were exposed initially. The sequence of surgical maneuvers allowed an orderly assessment of the injuries with good exposure while leaving the bolt in situ to reduce the risk of massive bleeding. Fingleton [5] emphasized the need for stabilization of the bolt before sternal retraction.
In this case a major source of morbidity was caused by peripheral embolization. Possible sources could have been from around the bolt before removal or subsequent clot formation from the aortic suture line.
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Acknowledgments
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We thank Michael Shapter, MCA, and Erica Holt, RN, for their assistance in the preparation of the pictures.
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References
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Demetriades D. Penetrating injuries to the thoracic great vessels. J Cardiac Surg 1997;12(Suppl):173-180.[Medline]
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Buchan K., Robbs J.V. Surgical management of penetrating mediastinal arterial trauma. Eur J Cardiothorac Surg 1995;9:90-94.[Abstract/Free Full Text]
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Cina S.J., Radentz S.S., Smialek J.E. Suicide using a compound bow and arrow. Am J Forensic Med Pathol 1998;19:102-105.[Medline]
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Mattox K.L. Thoracic great vessel injury. Surg Clin North Am 1988;68:693-703.[Medline]
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Fingleton L.J. Arrow wounds to the heart and mediastinum. Br J Surg 1987;74:126-128.[Medline]
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