Injury to the Chest With an Arrow Penetrating the Right Lung With Rent in the Right Atrium: A Case Report

A 17-year-old boy from a semi-extinct tribe of Chhattisgarh, India, presented to the NIMS EMD with a chest injury caused by an arrow that penetrated the right lateral side of his chest. He had been injured the previous day while playing in the jungle. The arrow was jutting from the third intercoastal space. An ECG revealed global ST elevations suggestive of pericarditis. A 2D echocardiogram reported a breach in the pericardium with a trivial pericardial effusion. A contrast-enhanced CT (CECT) reported moderate hemothorax on the right side with a breach in the pericardium, and the arrow was abutting the right atrium. The patient was immediately taken for surgery where a right anteroposterior thoracotomy incision was made, and the pleural cavity was entered through the fifth intercostal space. A massive hemothorax was present, along with dense interlobar lung and chest wall adhesions, and black-colored blood filled the pleural pockets. Meticulous adhesiolysis was performed, and the right middle lobe was found to be impaled by the arrow, with its tip abutting the pericardium.  

The right lung was mobilized, and control over its hilum and the right middle lobe was obtained before an attempt was made to dislodge the arrow. Due to its design, the arrow was immovable. The arrow was gently teased out through the right middle lobe. An underlying pericardial clot was identified, and minimal bleeding was present from the right middle lobe parenchyma. The arrow was removed, tip forward, after cutting its exterior shaft close to the skin. No significant air leak was present, which may have been due to the prior massive bleed sealing the air leak. The patient was placed on double lung ventilation to enable work on a single lung. There were frequent drops in saturation, during which the surgery had to be paused, and both lungs needed to be ventilated. Blood was noted in the endotracheal tube on the right side. The clot on the pericardium was dislodged to identify a spurt through it. Bleeding was noted after a mini pericardial window was created. Clots were then identified all around the heart and removed. A perfusion team was kept on standby to initiate immediate cardiopulmonary bypass through the thoracotomy access in case of uncontrolled bleeding. An RA clot was identified and teased out, revealing a rent, which was then closed with double-armed, pledgetted 5-0 Prolene sutures. The lung inflated well, and the air leak test was negative. A pericardial and pleural drain were placed for continuous drainage. The immediate postoperative chest X-ray of the patient, taken at the bedside in the AP view, showed well-expanded lungs with no CP angle blunting with drains in situ on the right side. The postoperative ECG showed resolved ST elevations. The pericardial drain was removed on postoperative day two, and the right pleural drain was removed on postoperative day three. The patient was discharged on postoperative day four in stable condition. 

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