Gunshot Wound to the Chest With Retained Epicardial Bullet

Gunshot wounds remain the most common cause of penetrating injuries in children and adolescents and the second leading cause of death among youth in the United States. Penetrating cardiac injuries carry a significantly increased mortality rate. The extent of damage caused depends on the type of firearm, the bullet used, the velocityand the trajectory. Therefore, rapid diagnosis and treatment is of the utmost importance. 

We report a case of a 19-year-old boy who presented to ouremergency department (ED) after sustaining a gunshot wound (GSW) to the right chest. In the ED, the patient was stabilized and a large hematoma was evacuated during a resuscitative thoracotomy. Further thoracotomy in the operating room was done with repairs of the penetrating injuries to the heart and lungs. No bullet was identified after careful inspection of the entire chest in the operating room. However, upon further postoperative imaging, a bullet was identified on chest X-ray and CT, lodged in the anterior aspect of the subepicardial right ventricular outflow tract. After a complicated hospital course, the patient was discharged by hospital day 30 in a stable condition with outpatient follow-up.

The decision to leave or retrieve a bullet should be made on a case-by-case basis depending on the clinical picture. In this case report, we have shown that leaving the bullet in place with close observation and appropriate imaging is feasible for selected patients.

Predictors of Positive Subxiphoid Pericardial Window in Stable Patients with Penetrating Injuries to the Precordial Region

BACKGROUND

Subxiphoid pericardial window (SPW) remains a valuable diagnostic tool for patients at risk of occult cardiac injuries. However, how to select patients that could benefit from this procedure remains unclear. We aimed to identify clinical predictors of positive SPW in patients with penetrating precordial injuries.

MATERIALS AND METHODS

Prospective data collection of 183 patients who underwent SPW for the exclusion of penetrating cardiac injuries during 2002 - 2004 at a level I trauma centre in Cali, Colombia. Patient's demographics, clinical characteristics, and injury information were obtained. Independent predictors of positive SPW were assessed using stepwise logistic regressions.

RESULTS

There were 41 positive SPW (22.4%). Unadjusted analyses demonstrated that stab/knife wounds (OR 2.48, 95% CI 1.17-5.25, p = 0.017), single wound (OR 14.61, 95% CI 1.9-110, p = 0.009), and clinical signs of pericardiac tamponade (OR 8.52, 95% CI 3.92-18.4, p < 0.001) were associated with increased odds of positive SPW. Conversely, systolic blood pressure (0.98, 95% CI 0.96-0.99) and stable physiological index (OR 0.31, 95% CI 0.14-0.65, p = 0.002) were associated with decreased odds. In multivariable analyses, signs of pericardiac tamponade (OR 6.37, 95% CI 2.78-14.6, p < 0.001), and single injuries (OR 12.99, 95% CI 1.6-102.7, p = 0.015) remained as independent predictors of positive SPW.

CONCLUSION

Emphasis on early recognition of the clinical signs of pericardiac tamponade could be the most important factor for the identification of occult cardiac injuries. Patients with multiple wounds to the precordial region who reached the hospital may not benefit from a SPW. However, high level of awareness is important because the incidence of occult cardiac injuries is not negligible.