Department of Clinical Reports

PASSAGE OF A HOLLOW NEEDLE INTO THE VENOUS BLOOD

STREAM TO THE HEART, THROUGH THE CARDIAC WALL,
ArjD INTO THE THORSX
REPORT OF A CASE

SHEPARD SHAPIRO, M.D.

NEW YORK, N. T.

T HIS report is one of a case in which a needle which was being used
for an intravenous injection became separated from the hub and
entered the blood stream.
The circumstances were as follows: A physic,ian was giving an in-
jection into the left cephalic vein of a 45year-old white man on May
28, 1938. Upon completion of the injection he applied pressure at the
point of puncture with a small pledget of cotton, in order to avoid
leakage, and attempt.ed to withdraw t,he needle. Only the hub of the
needle, however, remained attached to the syringe. Diligent search of
the surrounding t,issue failed to locate the lost part of the needle. The
patient did not complain of pain or other symptoms. Roentgenograms
of the arm and chest, taken the same day, failed to show the needle.
However, the patient was observed at frequent intervals thereafter, and,
on June 24, 1938, about one month after the injection, a posteroanterior
roentgenogram of the chest revealed a linear sha.dow, the dimensions
of which corresponded exactly to those of the lost needle. The needle
was lying horizontally at the level of the eighth t,horacic vertebra (Fig.
1). Fluoroscopic examination showed that the needle lay outside the
heart, and appeared to be embedded in the prepericardial fat between
the inferior surface of the apex of the heart and the left dome of the
diaphragm.
The patient has not had any complaint referable to the circulation,
heart, lungs, or pleura. Roentgenographic and fluoroscopic examination
of the chest on July 7, 1938, showed that t,he shadow was in the same
locat,ion. Four subsequent examinations, t,he last on March 27, 1940,
revealed no alteration in the position of the needle.
The electrocardiograms were normal. The blood pressure has been
constantly 120/80. The heart rate has avrraged.76 per minute, and the
Received for publication Oct. 5. 1940.
835
836 THE AMERICAN HEART JOURNAL

rhythm has been normal. Cardiac murmurs have never been heard, and
the size of the heart has remained normal. At present the patient is
active and works a.s a commercial artist, which is his usual occupation.

Fig. L-The arrows point to the needle shadow between the inferior surface of the
heart and the left dome of the diaphragm.

DISCUSSION

From its location in the chest, it is apparent that the needle must
have entered the heart, passed through its wall, and lodged in the silent
area where it now rests. The course of the needle after it entered the
venous blood stream must have been through the left cephalic vein,
axillary vein, subclavian vein (up to this point all of the veins possess
valves), innominate vein, superior vena cava, and, finally, the right
side of the heart.
There are three pathways by which foreign bodies may enter the
heart. The first, and most common, is directly through the chest wall,
as in the case of gunshot wounds or the thrust of a sharp instrument.
Examples of these a.bound in the literature.lm4
The second pathway is through tissue from a distant part of the
body; the foreign body is forced by muscular contraction along a more
or less circuitous route, possibly by following paths of least resistance,
until by chance it eventually reaches the thorax and the heart. It is
probable that only a sharp instrument, such as a nail or needle, can
 SHAPIRO : PASSAGE OF NEEDLE INTO VENOUS BLOOD STREAM 837

perform this feat. A striking example of this was reported by Rea and
Hoover;5 a needle entered the foot of a patient when he accidentally
stepped upon it, and four years later he died as the result of thoracic
disease induced by the passage of the needle through the pleura and
pericardium. At autopsy the needle was found lodged in the heart.
The third pathway is illustrated by the case reported in this paper.
Another remarkable instance of the same route was reported by Blaha.
In his case a soft rubber catheter was introduced into a gravid uterus
to induce an abortion, and, when the uterus expelled its contents, the
catheter was not among them. The patient became infected and died.
L4t autopsy the catheter, 24 cm. long and 4 mm. in diameter, was found
lying in a channel formed by the inferior vena. cava, the right auricle,
the superior vena cava, the left innominate vein, and the internal jugu-
lar vein. This case and the one described in this paper illustrate how
relatively large bodies may gain entrance into the venous blood stream
and be carried to the heart.
The importance of investigating the flexibility and sturdiness of each
needle before use, especially for intravenous injections, is emphasized
by the present report. It should be realized that the needle consists
of two parts, namely, a flexible cannula and a rigid hub, and that the
junction of these two parts is the weak spot in the construction of every
needle. It is consequently important (when administering any injec-
tion) not to introduce the needle more than three-fourths of its length,
so that, if it should accidentally become separated from the hub, it
might still be possible to grasp its free end before it becomes completely
submerged in the tissues.
SUMMARY

1. A case is reported in which a hollow needle entered the venous

blood stream, was carried to the heart, penetrated its wall, and came
eventually to lie in the prepericardial fat between the heart and the
diaphragm, without producing any untoward symptoms.
2. The pathways by which foreign bodies may enter the heart are
described.
3. The hazard described in this paper, although a rare one, warrants
the recommendation that the flexibility and sturdiness of needles be
carefully tested before they are put to intravenous use.
The author is grateful to Dr. A. 5. Hartstein and Dr. B. Kurz, of New York
City, for permitting him to examine their records of this case.

REFERENCES

1. Bland-Sutton, Sir John: A Lecture on Missiles as Emboli, Lancet 1: 773, 1919.

2. Cope, 2.: Extraction of Sewing Needle From the Heart, Lancet 1: 813, 1920.
838 THE AMERICAN HEART JOURNAL

3. Goldberger, H. A., and Cla,rk, H. E.: Migration of Needle into Heart Through
Chest Wall: Surgical Removal, Electrocardiographic and Roentgenographic
Studies, J. A. M. A. 105: 193, 1935.
4. Fair, George L.: Foreign Body in the Heart: Report of a Case With Retention
of a Large Needle With Recovery, New York State J. Med. 35: 453, 1935.
5. Rea, Charles, and Hoover, P. A.: An Unusual Case of a Needle Found in the
Heart at Necropsy, J. A. M. A. 109: 266, 1937.
6. Blaha, J.: Embolische Verschleppung eines FremdkGrpers (Gummikatheter)
ins Herz bei einem kriminellen Abortus, Zentralbl. f. Gynlik. 59: 746, 1935.
45 EAST 85 ST.