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Critical Care |

Penetrating Vascular Trauma Resulting in Bullet Emboli: A Case Report, Literature Review, and Recommendations

Ntesi Asimi, MD; Jess Thompson, MD; Terence O’Keeffe, MBChB
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University of Arizona Medical Center, Tucson, AZ


Chest. 2013;144(4_MeetingAbstracts):317A. doi:10.1378/chest.1705088
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Abstract

SESSION TITLE: Cardiovascular Critical Care

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Sunday, October 27, 2013 at 10:45 AM - 11:45 AM

INTRODUCTION: Although rare a bullet embolism following a penetrating vascular trauma requires a thorough investigation and timely diagnosis and management 1,2. Embolization of the heart is quite infrequent and usually involves the right heart and pulmonary vasculature 2. We present a unique case of a bullet migration from the carotid sinus to pulmonary vascular bed.

CASE PRESENTATION: A 25 year-old male trauma patient with a gunshot wound to the left face of unknown gun at unknown range was brought in to our Trauma Center. Glasgow Coma Scale (GCS) on arrival was 3T. Computer tomography (CT) imaging was consistent with bullet fragment in the right superior aspect of the posterior fossa just under the tentorum. The patient was stabilized and right lateral ventricular external drain was placed. Follow up CT (4hours after the initial one) was significant for increased edema, phenumocephalus, and absence of previously noted bullet fragment. A new stable metallic density within the heart silhouette was noted on a portable chest x-ray (CXR) approximately 5 hours later. Follow up CT (done 3 hours later) was significant for a 5mm metallic foreign body within vascular bed of partially collapsed left lower lung field just posterior to the heart. Given the patient’s critical and unstable neurological condition cardiothoracic surgery service recommended to continue broad spectrum antibiotics and to re-evaluate the bullet after patient stabilizes or in case the bullet dislodges or becomes symptomatic. Within 48 hours of admission, the patient was transferred to a highly specialized neurological center. At the time of transfer there were no complications associated with the bullet embolus.

DISCUSSION: The diagnostic and therapeutic management of penetrating injuries of the great vessels, particularly involving projectile embolization, continue to be controversial 2, 3. The lack of experience and centralized body of evidence contributes to the difference in recommendation for diagnosis and management.

CONCLUSIONS: Undoubtedly there is a need for evidence based guidelines to aid trauma surgeons in recognition, diagnosis and management of bullet emboli. Furthermore, establishing risk stratification and timetable of embolization would be of great value in treating penetrating vascular injuries with fragment migration.

Reference #1: HJS Binin, GP Artho, PD Vuong, DC Evans, T Powell. Venus Bullet Embolism to the Right Ventricle. The British Journal of Radiology. 2007;80:e296-e298

Reference #2: J Galante, JA London. Left Ventricular Bullet Embolus: A Case Report and Review of the Literature. The Journal of Emergency Medicine. 2010;39 (1):25-31

Reference #3: N Greaves. Gunshot Bullet Embolus with Pallet Migration from the Left Brachicephalic Vein to the Right Ventricle: a Case Report. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010;18:36-38

DISCLOSURE: The following authors have nothing to disclose: Ntesi Asimi, Jess Thompson, Terence O’Keeffe

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