Esmanhotto B.B.a,b · Vilar C.R.L.b · Hecke J.C.a · Veroneze B.a · de Lima W.F.c

Author affiliations
aDepartment of inner Medicine, Hospital e Maternidade São José dos Pinhais, São José dos Pinhais, BrazilbFaculty the Medicine, Faculdades Pequeno Príncipe, Curitiba, BrazilcDepartment of general Surgery, Hospital e Maternidade São José dos Pinhais, São José dos Pinhais, Brazil

Abstract

Self-stabbing is an uncommon an approach of suicide and attempt that suicide, greatly chosen through young men and also people through a psychiatric history. A curious situation of self-destruction attempt by self-stabbing with a huge pointed knife in a 56-year-old guy is presented which brought about a myocardial injury and was evaluated v a stroke after cardiorrhaphy.

Introduction

Suicide is a serious worldwide public wellness issue. It is among the height 20 leading causes of death worldwide, with more deaths due to suicide than malaria, chest cancer, war, or homicide. Close come 800,000 world die through suicide every year <1>.

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Methods that are provided in situations of suicide vary among populations and also communities, and over time. Self-stabbing is one uncommon technique of suicide, mostly chosen by young men and people v a psychiatric history <2-4>. The target of this short report to be to current an unusual and also rare nonfatal left-sided penetrating thoracic trauma, resulted in by impaling with a substantial pointed knife together a self-destruction attempt, caused a myocardial injury and also evolved through a stroke after ~ cardiorrhaphy.

Case Presentation

A 56-year-old male was gift at the emergency room. On initial presentation, the patient remained in a prone position, wake oriented (Glasgow Coma scale of 15), and also hemodynamically secure (blood press 125/74, heart rate of 80, respiratory rate 16, and also O2 99% in room air). The outside examination revealed penetrating knife injury in the left hemithorax, approximately 4 centimeter medially come the left nipple. The patient offers fluoxetine 20 mg/day for unipolar depression. Chest tomography depicted pneumomediastinum and pericardial effusion (Fig. 1). He was evaluated by trauma surgery and performed a thoracoscopic pericardial window that demonstrated myocardial injury (Fig. 2).


Fig. 1.

Chest axial noncontrast CT mirroring pneumomediastinum (white arrow) and pericardial effusion.


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Fig. 2.

brain axial noncontrast CT reflecting the appropriate MCA infarction. MCA, middle cerebral artery.


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Thoracotomy to be proceeded to fix a left atrial lesion adhered to by drain chest insertion. Postoperative electrocardiogram to be performed through ST elevation in the anteroinferior lateral region, mirroring ST elevation in V2, V4, D3, and AvF. Transthoracic echocardiography to be unremarkable.

One work after, the patient presented disproportionate left hemiparesis and dysphagia. Mind CT scan proved right middle cerebral artery infarction (Fig. 3) without midline shift, compatible through ischemic injury in the acute phase. After ~ 10 days, that remained partly recovered indigenous neurologic deficit. He was discharged come an inpatient psychiatric facility.


Fig. 3.

Left atrial rupture (white arrow) regarded by thoracotomy.


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Discussion

In the existing case, the inexplicable presentation of stroke after ~ a left-sided penetrating thoracic trauma, resulted in by impaling with a huge pointed knife together a suicide attempt was presented, demonstrating the importance of surveillance potential late complications native thoracic injuries, emphasizing stroke together a treatable and potentially deadly cause. Cardioembolic strokes can occur as a repercussion of any kind of cardiac insult the could cause the fulfillment of Virchow’s triad of endothelial injury, stasis, and hypercoagulability. Commonly encountered reasons include atrial disease, structural disease, valvular love disease, structural and also functional ventricular diseases, and myocardial infarction <5>. However, cardioembolic stroke because of myocardial atrial injury and also cardiography after suicide attempt is an unusual presentation.

Suicide is a frequent reason of fatality all end the world, and close come 800,000 civilization die by self-destruction every year, however self-stabbing is an uncommon method, constituting no an ext that 3% that suicides. Back stab wounds that the chest are a reasonably common type of penetrating chest trauma, no much more than 10.5% that them space self-inflicted <6>. The left hemitorax represents, wherein it is familiar for the heart, to represent the chosen site of self-inflicted wounds in a self-destruction or do the efforts of self-destruction <3, 4, 6>.

Three criteria are welcomed as classic for self-inflicted suicide and also attempts that suicide: the visibility of several self-inflicted stabs, hesitation marks, and the lack of garments <2, 3>. However, the presented situation did no resemble the classic cases. Over there was just 1 single incision and no suspicion marks.

Penetrating cardiac injuries have actually been taken into consideration lethal and also intractable. However, Rehn presented in 1897 the very first successful instance of cardiorrhaphy of the appropriate ventricle <7>. About 22–25% the trauma deaths are pertained to chest injuries, and 90% of cardiovascular lesions space originated indigenous the penetrating trauma <8>. Through respect to penetrating cardiac injuries, various ratios in between their instrument are discovered in the literature, v predominance the gunshot wounds (24.6%). Stab wounds are much less common and also account because that 10.3% of situations <9>.

The all at once survival rates of penetrating cardiac injuries range from just under 20 to 81% <8>. However, 60–80% that victims through such injuries dice at the step or ~ above the way to the emergency room, despite developments in rescue and also prehospital transport derived in the last 4 years <10>.

The reported patience was easily taken come the emergency room after ~ the self-destruction attempt v self-stabbing in the chest. The hospital had surgeons on standby wait for the victim brought by the ambulance, and also agility in care was vital for the patient’s survival.

Traumatic injuries have the right to be classified as immediate, early, and late. The immediate ones are related to hypovolemia, acidosis, hypothermia, and hypercoagulability, which reflect the severity the the lesions and their systemic repercussions <10>. The patience in question shows signs of hypovolemia, which was corrected at an early stage in the emergency room.

The most typical early complications room acute myocardial infarction, arrhythmias, and infections. The literature around late complications is extensive; however, the many reported space intracardiac shunts, cardiac tamponade, fistulas, embolization, left ventricular pseudoaneurysm, tricuspid regurgitation, aortic regurgitation, mitral regurgitation, congestive love failure, pericarditis, endocarditis, and also iatrogenic coronary artery stenosis <9>. Patients who present themselves with unusual associations represent challenges and learning opportunities. The relationship is even greater when the technique involves various specialties, such as psychiatry, cardiology, thoracic surgery, neurology, and neurosurgery.

Statement the Ethics

Written educated consent was acquired from the patience for publishing of this case report and any accompanying images. All personal and identifiable details of the patients were completely anonymized. We strictly complied with the tip of the 1964 declaration of Helsinki and its related good practice guidelines in composing this instance report.

Conflict of attention Statement

The writer declare that they have actually no conflicts of attention to declare.

Funding Sources

No grant or assistance was received.

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Author Contributions

B.B.E.: conceptualization the the overall scholastic content, creating of the preliminary version of the manuscript, and also reviewing and approving the final manuscript before submission. C.R.L.V.: cowriting of the preliminary version, modifying the final version, and also approving it before submission. J.C.H. And also B.V.: clinically cared because that this patient together physicians. W.F.L.: conceptualization that the academic content related to the surgery.