Successful treatment of a penetrating pulmonary artery injury caused by a Japanese sword in a patient transported by a physician-staffed helicopter

Sir, We herein present a case of successful treatment of a penetrating pulmonary artery injury caused by a Japanese sword (katana) in a patient transported by a physician-staffed helicopter. A 91-year-old male stabbed his chest and abdomen and cut his head with a katana and was found in a coma by his family. His history included dementia, schizophrenia, hypertension, and diabetes mellitus. A physician transported by a helicopter checked the patient at a rendezvous point in an ambulance and found that the katana had penetrated the patient’s body from the fourth intercostal of the left anterior chest to the back [Figure 1]. The patient was in a deep coma and also a state of severe hemorrhagic shock. His venous route and airway were secured, and he was transported to our hospital. He remained in a coma with shock and demonstrated left pneumoderma in the left chest; therefore, he underwent placement of an indwelling chest tube, followed by drainage of 500 ml of hemorrhagic fluid. Permissive hypotensive therapy to maintain the systolic blood pressure from 60 to 80 mmHg was selected with transfusion of blood type O, and emergency thoracotomy was performed in the operating room. The patient temporally exhibited pulseless electrical activity due to massive hemorrhage, and fluid resuscitation resulted in spontaneous circulation. Injuries of the lingual, left pulmonary artery, and diaphragm were found, and primary closure of the pulmonary artery with clamping of the pulmonary hilum, primary closure of the diaphragm, and lobectomy of the lingual region were performed. The abdominal stab wound did not reach the intra-abdominal cavity and was also closed. After the operation, the patient developed pyothorax and was treated with antibiotics. He achieved a full somatic recovery and was transferred to a psychiatric hospital. The patient was successfully treated, despite his advanced age and severe shock state resulting from injury of major thoracic vessels.[1-4] The key to success was a multidisciplinary approach, including early medical intervention, transportation using a physician-staffed helicopter, and the administration of permissive hypotensive treatment and emergency thoracotomy with clamping of the pulmonary hilum.