Two-dimensional and color Doppler echocardiographic diagnosis of penetrating missile wounds of the heart: chronic complications from intracardiac course of a bullet

Conservative management of retained cardiac missiles: case report and literature review

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

The echocardiographic diagnosis, characterization, and extraction guidance of cardiac foreign bodies

Echocardiography is ideal for localizing cardiac foreign bodies and for characterizing associated cardiac and vascular injury before and during extraction. We report 5 cases of traumatic and iatrogenic cardiac foreign bodies that illustrate the central role of transthoracic and transesophageal ultrasonography in the management of these patients.

Ultrasound detection of foreign bodies and procedure guidance

As emergency physicians become familiar with the use of ultrasonography, this safe procedure will likely become a standard technique having multiple uses in the emergency department. Ultrasonography assists in foreign body localization and retrieval and is potentially important in applications, such as reliable endotracheal tube placement, visualization of ingested medication, vascular access, and drainage of collected fluids.

Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: a prospective study

One hundred five hemodynamically stable patients with penetrating thoracic trauma were prospectively evaluated for occult cardiac injury. All patients underwent transthoracic echocardiography (ECHO) and subxiphoid exploration (SXE). Those with positive SXE underwent exploration. Results are calculated based on operative findings of significant injuries. For the entire group, SXE was more sensitive than ECHO (sensitivity, 100% vs. 56%; specificity, 92% vs. 93%; and accuracy, 92% vs. 90%, respectively). The SXE missed no injuries in this group. Eight of 17 patients, however, with positive SXEs had insignificant injuries at sternotomy. Seven patients had positive ECHO, but no significant injury. The ECHO missed four significant injuries. When comparing SXE with ECHO in patients without hemothorax, however, sensitivity (100% vs. 100%), specificity (89% vs. 91%), and accuracy (90% vs. 91%) were comparable between SXE and ECHO. We conclude that ECHO has significant limitations in identifying serious cardiac injuries in patients with hemothorax. For hemodynamically stable patients without hemothorax, ECHO missed no significant injuries and may be an acceptable diagnostic option for detecting significant cardiac trauma in patients with injuries in proximity to the heart.

Use of transesophageal echocardiography in the detection and consequences of an intracardiac bullet

A 17-year-old male sustained a gunshot injury to the chest. Transesophageal echocardiography showed the presence of a retained bullet in the pericardium and the absence of an intracardiac shunt, which provided important information for the treatment of the patient.