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Background: Methemoglobinemia is a relatively common, potentially fatal syndrome resulting from oxidative stress. Of the numerous causes identified, toxins are the most common precipitating event., Objectives: Describe methemoglobinemia after a stab wound in a man with previously undiagnosed cytochrome b5 reductase deficiency., Case Report: In this case report, we describe a 27-year-old man with no past medical history who developed clinically significant methemoglobinemia after a mediastinal stab wound. After an extensive toxicologic work-up failed to reveal the etiology of the symptoms, genetic testing was performed, which revealed the individual to have a previously undiagnosed cytochrome b5 reductase deficiency. It is hypothesized that the physiologic stress from the expanding mediastinal stab wound resulted in enough oxidative stress to cause methemoglobinemia in this predisposed individual. A discussion of methemoglobinemia ensues., Conclusion: This case describes an uncommon presentation of a common toxicologic condition and presents a discussion regarding the evaluation, management, and pathophysiology of methemoglobinemia., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Aortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm., Objectives: To remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF., Case Report: We discuss the case of a 25-year-old man who developed an aortoduodenal fistula weeks after a stab wound to the abdomen. AEF can occur anywhere along the gastrointestinal tract and can therefore present as either upper or lower tract bleeding. The expected triad of pain, pulsatile mass, and gastrointestinal bleeding is unfortunately rarely present, making diagnosis difficult. Patients often present with a self-limited herald bleed that precedes the fatal exsanguination by hours to days. Diagnosing the fistula at the time of the herald bleed can be difficult but lifesaving. Imaging studies are often misleading and only delay definitive operative treatment. Even with prompt diagnosis and treatment, mortality is high; without repair, it is 100%., Conclusion: This case highlights the importance of suspecting and quickly recognizing AEF based on history and physical examination alone. After extensive preoperative imaging to confirm the diagnosis, this patient nearly died in the operating room as surgeons took down adhesions trying to reach the fistula to repair it., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Traumatic ventricular septal defect (VSD) occurs in approximately 5% of blunt or penetrating cardiac injuries and can result in rare complications., Objectives: To report the serious complication of stroke after a traumatic VSD., Case Report: A 27-year-old man with no previous medical history presented to the Emergency Department with aphasia and right hemiparesis after a stab wound to the chest. He underwent emergent evacuation of a pericardial effusion and repair of a right ventricular wall perforation. Head computed tomography revealed left middle cerebral artery infarct. Post-operatively, he was noted to have a cardiac murmur, and echocardiogram revealed a VSD. The VSD was surgically repaired without complication., Conclusion: Stroke can complicate traumatic VSDs., (Published by Elsevier Inc.)

A rare case of stab wound of the neck with contralateral hemo-pneumothorax with a mediastinal shift is presented. After tube thoracostomy and computed tomography, the patient had angiographic coil embolotherapy of transected internal mammary artery (IMA). Subsequently, neck exploration with the repair of sternocleidomastoid was done. The patient underwent decortication on the 11(th) post-operative day for persistent residual hemothorax. IMA transection most often occurs from ipsilateral parasternal stab wounds and rarely from iatrogenic trauma. It is important to recognize the presentation of this rare entity as appropriate aggressive diagnostic and therapeutic interventions may be warranted., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Blunt carotid arterial injuries are uncommon. Motor vehicle crashes are the most frequent cause, but this type of vascular injury can be secondary to any direct blow to the neck, intraoral trauma, or strangulation. Types of vascular injuries include dissection, pseudoaneurysm, thrombosis, rupture, and arteriovenous fistula formation. Patients with pseudoaneurysm of the internal carotid artery will usually present with neurologic complaints, ranging from the minor to complete stroke. On physical examination, neck hematoma, bruits, pulsatile neck mass, or a palpable thrill may be found. However, in 50% of cases, no external signs of neck trauma are observed. Onset of symptoms may occur within a few hours to several months after the initial injury. Angiography is considered the gold standard for diagnosis, but carotid Doppler ultrasound recently has been shown to be very sensitive in detecting these types of injuries. Treatment of pseudoaneurysm is often surgical, with endovascular stenting.

Pneumothorax (PTX) in patients with penetrating thoracic trauma is routinely ruled out with serial chest radiographs (CXRs). This study examined the efficacy of a shortened time period between initial and follow-up radiographs. Patients with penetrating torso injuries treated at a Level-1 trauma center received a CXR during their initial evaluation. If no pneumothorax or hemothorax was noted, and the patient did not require immediate admission to the Intensive Care Unit or operating room, a repeat chest film was taken at 3 and 6 h. Findings were treated as clinically indicated, and patients were discharged home if the last radiograph revealed no evidence of pathology. Over a 15-month period, 116 patients were evaluated for penetrating thoracic injuries (93 stabbings, 23 gunshot wounds) and had no pneumothorax detected on initial CXR. Two patients had pneumothorax detectable only by computed tomography. One patient had a normal initial CXR, but developed a PTX on the 3-h film, requiring tube thoracostomy. No patients developed a PTX on the 6-h study that was not present on the initial or 3-h CXR. In conclusion, extending the time between initial and final CXRs to 6 h in patients with penetrating thoracic trauma provided no additional information that was not available on the 3-h film.

Stab wounds to the spinal cord are relatively uncommon in North America, but even rarer is the presentation of such an injury in a delayed fashion. We report a case of a 31-year-old male who presented with neurologic deficit 4 weeks after a stab wound injury to the spine. Because of worsening neurologic deficit, the retained knife fragment was operatively removed, and the patient had an uneventful recovery. The management of such an injury is discussed, with a review of the literature.

We describe a case of cardiac tamponade due to pulmonary artery laceration as a late sequela in a patient who had sustained penetrating chest trauma. A 35-yr-old man presented to our emergency department complaining of pleuritic left chest pain, shortness of breath, and fever 19 days after being hospitalized for a stab wound to the left chest. During his first hospitalization, chest X-ray study, echocardiogram, and central venous pressure determination were all normal. On second presentation, he had a cardiac tamponade and underwent a median sternotomy. A pulmonary artery laceration was discovered and repaired. The postoperative course was complicated by readmission for postcardiotomy syndrome. This case demonstrates that late and unexpected complications can occur in patients with penetrating chest trauma and a normal initial evaluation.

A 21-year-old male presented to the trauma unit after he was stabbed once with a knife in the left anterior chest. The patient was awake and combative, very intoxicated, with a systolic blood pressure of 90 mmHg by palpation and a heart rate of 110 beats per min. Physical examination revealed distended neck veins, a single 1.5 cm stab wound to the left parasternal area at the third ICS (noted by clip on x-ray, Fig. 1), poorly auscultated heart sounds, and palpable femoral pulses that went away with inspiration. Chest radiograph (Fig. 1) showed a "pear-shaped" cardiac silhouette, though not markedly enlarged, and a significant left hemothorax. A diagnosis of acute pericardial tamponade was made, and the patient was taken immediately to the operating room for thoracotomy and successful repair of a stab wound of the right ventricle. Figure 2 (courtesy of Richard Wolfe, MD, Massachusetts General Hospital, Boston, MA) presents an example of an echocardiogram depicting a pericardial effusion. Pericardial fluid is imaged as a black (hypoechoic) crescent area separating the apex of the heart from the pericardium, seen as a white ring (arrow) at the inferior aspect of the scan. Tamponade is defined sonographically as the presence of both pericardial effusion (PE) and diastolic collapse of the right ventricle. Figure 3 (courtesy of Michael H. Picard, MD, of Harvard Medical School, Boston, MA) demonstrates the collapse of the right ventricular outflow track (RVOT) and its position relative to the left ventricle (LV), the left atrium (LA), and the aortic valve (AV).

We present the case of a 21-year-old male with recurrent, severe gastrointestinal hemorrhage, who eventually proved to have an aortoduodenal fistula. The fistula arose from an aortic repair done after a stab wound four years previously. The diagnosis of aortoenteric fistula was not initially suspected because of the patient's age, inability to provide details of his previous surgery, and false-negative endoscopic and radiologic studies. We believe that this is the youngest reported patient who developed an aortoenteric fistula after aortic surgery. The presence of an aortoenteric fistula should be suspected in any patient with a GI bleed and previous aortic surgery, regardless of the patient's age.

A 39-year-old male arrived in the emergency department with multiple stab wounds to the chest. A pneumopericardium was present on initial chest x-ray study. He subsequently developed hypotension, tachycardia, an elevated CVP (36 cm H2O) and a pulsus paradoxus. All parameters improved following removal of 100 cc of air by pericardiocentesis. The etiology, diagnosis, pathophysiology, and treatment of tension pneumopericardium are discussed.

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.