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Pulmonary Artery Bullet Embolism after Cardiac Gunshot Wound

Pulmonary artery bullet embolism is a rare and serious complication of penetrating gunshot wounds (GSWs) that poses a unique diagnostic and clinical challenge for trauma physicians. We present a case of a victim of a GSW to the left chest in which the bullet entered the right ventricle (RV) and embolized to the left main pulmonary artery, ultimately leading to death despite prompt management of traumatic injuries. Pulmonary artery bullet embolism is a rare complication that should be considered in GSW patients who arrive hemodynamically unstable, have a discrepancy in the number of GSWs, or with radiographic evidence of a retained projectile outside of the expected trajectory of the injury. A literature review suggests that the management may range from observation, to endovascular retrieval or complex operative interventions, with various patient outcomes. The final location of the bullet and the extent to which pulmonary artery flow is obstructed are significant contributors to morbidity and mortality. Pulmonary artery bullet embolism can present as a devastating scenario that should be considered in any GSW patient presenting with hemodynamic instability. Chest radiography and/or CT imaging may be imperative in the diagnosis. Swift recognition and surgical intervention may lead to improved outcomes. In the current climate of heated gun control debates and well-publicized mass shootings, this case presents a unique and rare complication of a GSW that was well documented and publicized in the local community. It affected the lives of all involved with the deceased, including the physicians who treated her. Pulmonary artery bullet embolism is a rare but potentially devastating complication of penetrating trauma that poses a unique clinical challenge for trauma physicians. Since the first report of traumatic nonthrombotic embolism by Thomas Davis in 1834, there are less than an estimated 200 reported cases of bullets taking migratory intravascular paths.1 Most reported cases involve peripheral vascular injuries, and there are few reported cases of patients with penetrating cardiac injuries secondary to GSWs in which the bullet migrated intravascularly and survived to reach the hospital. Here, we present a case of a bullet entering a patient’s RV and embolizing to the left main pulmonary artery, ultimately resulting in obstructive shock and death despite prompt management. A discussion of the hospital course and a literature review are included. A 14-year-old female arrived intubated by EMS to the trauma bay with a GSW to the left chest along the midclavicular line near the level of the 4th rib. There was witnessed cardiac activity in the prehospital setting, but the patient subsequently went into cardiac arrest en route. An emergent resuscitative left anterolateral thoracotomy was performed. Gross blood was immediately evacuated from the pericardial space with return of an organized cardiac rhythm and pulsatile arterial flow. A penetrating wound to the heart was visualized in the anterior RVand repaired with Prolene sutures. Large bore central venous access was obtained, and the massive transfusion protocol was initiated. The patient was taken expeditiously to the operating room for open thoracic exploration via median sternotomy. Despite control of cardiac hemorrhage and resuscitative efforts, the patient continued to decline with intermittent cardiac arrest requiring intracardiac epinephrine injection and open cardiac massage. The exposure was extended to a midline laparotomy to evaluate for occult intra-abdominal bleeding. No intra-abdominal sources of hemorrhage were found. The remainder of the heart was free of injury with no exit wound. No other occult injuries were identified in the thoracic or abdominal cavities. Despite aggressive resuscitation and control of cardiac hemorrhage, the patient continued to become increasingly Address correspondence and reprint requests to David Testrake, M.D., General Surgery Program, Wright State University Boonshoft School of Medicine,Miami Valley HospitalWeber Center for Health Education, 7th Floor, 128 East Apple Street, Dayton, OH 45409. E-mail: David.Testrake@wright.edu.