ReviewThe Evolving Management of Venous Bullet Emboli: A case series and literature review
Introduction
Penetrating gunshot wounds present a wide range of unique injury patterns. Commonly, by ascertaining the anticipated tract of the projectile, reasonable estimates of the associated injuries may be predicted. Although rare, bullet emboli present an exception to the predicted injury pattern and pose a challenging diagnostic and therapeutic dilemma. Intravascular bullet migration through the arterial or venous circulation has been sporadically reported in the literature. Due to the relative scarcity of this event, no management guidelines are universally accepted. It is generally agreed that arterial emboli should be extracted and both open and endovascular techniques have been used. Venous emboli are usually asymptomatic with the majority of those reported lodging in the right heart or pulmonary arterial tree. Management guidelines for venous emboli are less uniform and both extraction and observation have been described.26, 46 Evolution of endovascular techniques for bullet extraction has anecdotally decreased morbidity by decreasing the need for thoracotomy, sternotomy and cardiopulmonary bypass, previously required for operative access and removal of centrally lodged bullet emboli. We present four cases of venous bullet embolism and their subsequent management from level one trauma centres in an attempt to better characterise the treatment and diagnosis of these challenging injuries.
Section snippets
Case 1
A 22-year-old male presented after sustaining a large calibre gunshot wound to the left chest. The patient was alert, responsive, and haemodynamically stable at presentation but appeared pale and diaphoretic. He had undergone needle decompression of his chest in the field secondary to decreased left-sided breath sounds. Upon presentation, a left-sided thoracostomy tube was inserted with evacuation of 700 ml of blood. A chest X-ray revealed clear lung fields bilaterally and a foreign body in the
Discussion
The first case report of foreign body embolus is attributed to Thomas Davis in 1834 and involved not a bullet, but a wooden fragment embolising from the venous circulation to the right ventricle.7 Sporadic case reports have followed in the literature. The diagnosis of bullet embolism is often difficult and is commonly the result of one of three observations. First, an incongruent number of entry and exit wounds without intra-operative or radiographic confirmation of the presence of the bullet
Conflict of interest statement
None declared.
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