Fight-Picker

Attack One crew members are just clearing another call when they are dispatched to a report of a fight at a bar. The dispatcher reports the police have been on scene for a few minutes and things are safe for the crew to begin patient care.

As crew members approach the scene, it appears a number of persons have been involved, as there are several individuals sitting in handcuffs on the curb, against a wall and in several police vehicles. One officer directs the EMTs to their patient, who sits on a curb with several other individuals, all in handcuffs.

The officer reports the young man has some injuries to his hands and knees. They need him checked before he is taken to jail, and request the blood on him be cleaned off. The officer says the injuries are likely related to a gang fight, but no guns were involved. He says some people thought brass knuckles were used by some participants.

The patient is a 28-year-old male who is not completely cooperative. He says he was “sucker punched” from behind by “some dudes” who knocked him to the ground. He reports he swung at them but missed and hit a table. He smells of alcohol and reports he had a few beers over the course of the evening. He has no signs of injury to the head, face or neck and reports no loss of consciousness. He is a healthy man on no medicines.

The Attack One paramedic looks over the wounds as the EMTs get vital signs and clean abrasions on his right hand and knees. As the paramedic finishes taking the history, he notices more blood is dried across the young man’s shirt and bare chest. He asks the EMT to clean up that blood as well. The paramedic examines the man’s right hand carefully as the blood is removed and notices only some small abrasions on the palm and fingers. There are none over the dorsal side of the hand and no bony injury that can be seen. The paramedic is aware of “fight bites,” which occur when a combatant strikes another person in the mouth and ends up with abrasions or lacerations over the dorsal side of the hand; these have a high risk of getting serious infections. The paramedic inspects the entire hand, questions the patient again about the possibility that he hit anyone in the mouth with the palm side of his hand, and has the patient move all his fingers while he checks each one carefully. The patient denies any injury of that type, and the wounds are all very superficial.

“Would you check his chest with me, please?” the EMT requests as he cleans the blood there. “These are actually little lacerations or abrasions, not just dried blood from his hands.”

They use some saline and gauze to clean dried blood across the lower front of the man’s chest, out to the left lateral chest wall. There are several areas that look abraded and a couple of small lacerations, particularly along the lower edge of his sternum. There is another small laceration on his left lateral chest wall.

“What caused these?” the paramedic asks.

“Don’t know,” the patient reports. “The dude just came up behind me and thunked me on the chest and knocked me to my knees.”

The wounds ooze a little blood as they’re cleaned, and the man’s chest wall is a bit tender near them. The other crew member has finished taking vitals and reports only that the man has a little elevation of his heart rate.

The paramedic is just about to pull out the patient refusal sheet and let the officers witness the patient refusing care, but that little voice that speaks in a provider’s head at 2 in the morning suggests the patient really should be checked further before he heads to jail. Those wounds on his hand may, in fact, be dangerous.

The patient is not thrilled about going to the hospital, and the officer in charge would certainly prefer not to break up his crew to take him there. They are almost certain this was a gang-related brawl and concerned that further violence may take place at the jail or in the streets that night. But the paramedic feels it is the right care for the patient.

As they load the patient into the ambulance, a second set of vital signs shows a heart rate that’s still elevated and blood pressure that’s down a little. The Attack One crew decides on transportation to the local trauma center and notifies them of the patient’s injuries. Part of their transportation choice is due to the good security force at the trauma center, and their plan is to notify the police officers already at the hospital that the fight may be gang-related and that further violence may occur anywhere that night. They would prefer not to have that discussion in front of the patient, who won’t say if he is a gang member or not.

The patient becomes a little more vocal and belligerent during transport. The crew has to work to get his cooperation as they attempt to get one more set of vital signs. They note his heart rate is even faster, and his blood pressure has now dropped below 100 palpable. The patient offers no new complaints as they enter the emergency department.

Hospital Course

On arrival at the ED, the paramedic requests that the trauma staff evaluate the patient, because something appears to be going on, although it is not clear what may be causing the slow drop in blood pressure and steady increase in heart rate. The patient continues to be fairly quiet and uncooperative and doesn’t offer any complaints of pain.

He is assessed by an emergency physician, who checks the hand and knee wounds, finds no head trauma and then opens the patient’s shirt to examine the chest. The injuries are again covered in a small amount of dried blood, and the physician pokes around at each of them on the chest wall. The edge of one wound, near the sternum, appears to be just an abrasion and tiny skin laceration, but the physician cleans it with saline and then pulls on the edges. This reveals a deeper penetrating injury. He tells the patient he is going to check it further, and numbs the skin with some lidocaine and then takes a small probe and enters the chest wall.

“This may be much more serious,” the physician tells the patient, then quickly starts directing the Attack One crew and nursing staff to action. They get IVs started, place the patient on a cardiac monitor, perform a 12-lead EKG, snap a chest x-ray and activate the trauma team. In another five minutes the patient looks much worse, with a heart rate of 154, blood pressure of 70 and pale skin. He now complains of chest pain. The 12-lead shows some type of injury, but not signs of an acute MI. The trauma team looks at his chest x-ray carefully but cannot find a pneumothorax or a large heart.

They probe the chest wound again, and it appears the wound extends deep into the chest. The patient still cannot provide any history of what he was hit with. At this point the emergency physician conducts an ultrasound on the patient’s chest, and as the patient’s consciousness starts to wane, the lead trauma team member wheels him toward the operating room.

The Attack One crew members are ready to go back in service when the physician calls them into the consultation room.

“This patient is still critical, but could have died had you not transported him,” he says. “We are almost certain that chest wound is from an ice pick or something similar. It is likely that a very talented killer targeted that guy and snuck behind him, stabbed him quickly and disguised it by slugging him and throwing him to the ground. The police you guys activated who have been hanging out here to prevent any violence think he’s one of the gang leaders and probably was marked to be killed tonight.”

The emergency physician and one of the police officers go on to describe the small ice picks that can be jabbed into the chest wall and heart very quickly, barely producing a wound, yet inducing a bleeding injury into the cardiac sac that leads to slow deterioration. Eventually that slow oozing of blood produces cardiac tamponade, and then shock and death. The emergency physician used the ultrasound to look at the pericardial sac, and it was full of blood. That is why the patient was immediately taken to the OR.

On their next shift the Attack One crew is told that the patient in fact had a small jab wound into the heart and a pericardial sac that had filled with blood. The injuries were repaired, and he is likely to recover completely. The news media reported that this young man was in fact one of the gang leaders involved in a turf war. Violence between the groups continued.

Case Discussion

Cardiac tamponade is pressure on the heart that compromises its pumping capability, resulting from blood or other fluid building up inside the sac that covers and contains the heart (the pericardial sac). That pressure does not allow the heart muscle (the myocardium) to expand fully, and therefore its pumping capability is progressively inhibited. The quicker the fluid builds up (minutes to hours), the worse the compromise of the heart’s function.

In this case the ice pick injury came through the chest wall and pericardial sac, then lacerated a small artery in the front of the heart. Blood leaked out of the artery and into the sac, quickly filling the sac and pushing against the heart. These small lacerations through the chest wall and pericardial sac seal themselves very quickly, and the blood can’t flow out of the chest wall to relieve the pressure. There is a slow progression of heart compromise until a certain threshold is reached, and then the heart fails quickly, ultimately leading to death.

The condition of cardiac tamponade can occur from trauma, as in this case. There are also medical causes, like cancer, infectious pericarditis and heart surgery. It can also occur when a patient has an indwelling central line that erodes through a central vein, allowing infused fluids directly into the pericardial sac. In these cases the fluid buildup is typically very slow, and the patient may have onset of symptoms over weeks or months. In those cases the symptoms may include difficulty breathing, chest pain and palpitations.

The signs of cardiac tamponade are falling blood pressure, tachycardia, distended neck veins and heart sounds that are difficult to hear with a stethoscope. In trauma, these signs may progress quickly and be very difficult to find. Therefore, a test that looks for fluid in the pericardial sac, like ultrasound, may be the only rapid way to find the problem.

Treatment is by removing the fluid from the sac, correcting whatever problem caused it and not allowing the fluid to recollect.

This case demonstrates the need for careful evaluation of all injuries, even when the patient is not fully cooperative. Even subtle injuries can indicate life-threatening problems inside. Ice pick injuries are the mark of a sophisticated fighter, and the injuries they produce can be hidden intentionally. In this case the attacker used a very small ice pick and a technique that allowed the injury to be disguised.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He was assistant fire chief and medical director for District of Columbia Fire and EMS. Jim also served as chair of ASTM Task Group E54.02.01, which develops standards for hospital preparedness under Committee E54 on Homeland Security Applications. He spent 32 years as a firefighter and EMT. Contact him at jaugustine@emp.com.