Reimplantation of a left internal thoracic artery during repeat coronary artery revascularization: early and midterm results.

Discussion Impalement injuries usually occur at construction sites or in motor vehicle crashes or are caused by falling objects. It is crucial to leave the impaling object in situ and remove it under controlled conditions in the hospital. Careful extraction with minimal movement of the impaling object prevents further tissue damage and blood loss. Therefore most authors advise removal under direct vision. In our case a computed tomographic scan revealed a bilateral hematothorax. Chest tubes were inserted to drain both sides, and 1.5 L of blood was removed from the left side within a few minutes. The patient was immediately taken to the operating room with the aim of controlling bleeding and removing the iron rods from the left thoracic cavity under direct vision. The situation was rendered even more dramatic because the patient had refused to receive blood under any circumstances. The rapid loss of more than 40% of blood volume is usually life-threatening. For acutely anemic patients, the American Society of Anesthesiologists Task Force on Blood Component Therapy has advised that transfusion is almost always indicated when hemoglobin concentration decreases to less than 6 g/dL. Our patient, however, survived a much lower concentration without organ damage apart from paraplegia caused by one of the impaling rods. His survival is certainly not a common clinical experience. The lesson we learned from this case is that an otherwise healthy subject can tolerate the loss of more blood than is commonly believed. Rapid assessment of the injury with careful hemostasis after removal of the impaling objects under direct vision together with appropriate fluid replacement was able to save a patient with an extremely unusual and severe impalement injury.