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Khorgami M, Khalaj F, Gholampour M, Tatari H. Missile embolism from pulmonary vein to left ventricle: report of a case. Front Cardiovasc Med 2024; 11:1342146. [PMID: 38464844 PMCID: PMC10920231 DOI: 10.3389/fcvm.2024.1342146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/22/2024] [Indexed: 03/12/2024] Open
Abstract
Missile embolization is rare in penetrating trauma, occurring in 0.3% of cases. Bullet embolism into the left ventricle is less frequent, with few instances described in the literature. This paper describes an instance of left ventricular bullet embolism from the pulmonary venous system following gunshot chest trauma. A 7-year-old boy sustained a gunshot wound to his chest during an assault accident. Despite thoracic pain, he remained conscious and exhibited vital signs. A CXR and CT scan revealed a bullet in the left mediastinum. A left thoracotomy was performed to remove blood and clots from the pericardium. The patient was sent to a tertiary referral hospital for further investigation. The patient underwent elective surgery to remove the foreign body from inside the heart. The procedure involved a partial thymectomy and pericardial opening, and the patient was released from medical care after 14 days. After 6 months, there were no signs or symptoms of cardiothoracic infection or evidence of mitral valve regurgitation in echocardiography.
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Affiliation(s)
- Mohammadrafie Khorgami
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fattaneh Khalaj
- Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maziar Gholampour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Tatari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Sozzi M, Inaba K, Schellenberg MA, Matsushima K, Martin MJ. Dangerous passage: the utility and accuracy of modern chest computed tomography in penetrating thoracic injuries with potential transmediastinal trajectory. Eur J Trauma Emerg Surg 2023; 49:2439-2445. [PMID: 37358631 PMCID: PMC10728241 DOI: 10.1007/s00068-023-02315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
AIM The aim of this study is to evaluate utility and reliability of chest CT as a standalone screening modality for stable patients with thoracic GSWs and potential transmediastinal trajectories. METHODS All patients with thoracic GSWs over a 5-year period were identified. Unstable patients requiring immediate surgery were excluded and the remaining underwent chest CT with intravenous contrast. Sensitivity and specificity for clinically significant injuries were tested against an aggregate gold standard of discharge diagnosis including imaging, operative and clinical findings. RESULTS A total of 216 patients met inclusion criteria and underwent chest CT. After imaging, 65 (30.1%) had indication for immediate surgery, of which 10 (4.6%) underwent a thoracic procedure for chest injuries while 151 (69.9%) were selected for nonoperative management (NOM). 11 (5.1%) required a delayed thoracic operation, none due to injuries missed on CT. The remaining 140 (64.8%) underwent successful NOM. Up to 195 (90.3%) patients had successful NOM of thoracic injuries. Only 9.2% required additional imaging, all negative. CT identified a cardiac injury in one case and a vascular injury in two cases, all confirmed by surgery, while one thoracic IVC injury missed on CT was found intraoperatively. 2 patients had CT suspicious for esophageal injury, ruled out by following investigations. There was one death in the total cohort, none in the NOM group. CONCLUSIONS Modern high-quality CT provides highly accurate and reliable screening modality for penetrating chest and mediastinal injuries and can be used as a standalone study in most patients or to guide further tests. Chest CT facilitated successful NOM.
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Affiliation(s)
- Marco Sozzi
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA.
| | - Kenji Inaba
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Morgan A Schellenberg
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Matthew J Martin
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
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Sozzi M, Wu Y, Matsushima K, Schellenberg M, Inaba K, Martin M. Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma. Am Surg 2023; 89:4018-4024. [PMID: 37165630 DOI: 10.1177/00031348231175451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults. METHODS Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management. RESULTS Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation. CONCLUSION Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.
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Affiliation(s)
- Marco Sozzi
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Yutung Wu
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Morgan Schellenberg
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Kenji Inaba
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
| | - Matthew Martin
- LAC+USC Medical Center, Division of Trauma and Acute Care Surgery, Los Angeles, CA, USA
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Benjaout K, Azzouzi SE, Brik AA, Alaoui S, Madani M. [Bullet fragment in the interventricular septum : Is surgery always obligatory ?]. Ann Cardiol Angeiol (Paris) 2023; 72:56-59. [PMID: 36473806 DOI: 10.1016/j.ancard.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Cardiac gunshot injuries are fatal and very challenging to manage for surgeons. Unfortunately, there is no consensus regarding the management of these patients. CASE PRESENTATION We report an unusual case of a cardiac injury after an indirect gunshot to the heart. The 59 years-old male was hemodynamically stable which allowed us to do further investigations revealing a bullets fragment in the interventricular septum without other complication. Conservative management was decided with a careful regular follow-up. CONCLUSION Cardiac gunshot injuries must be managed aggressively in hemodynamically unstable patients. In stable patients, further investigations can be done to allow decision-making.
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Affiliation(s)
- Kaoutar Benjaout
- Cardiac Surgery Department, University Hospital of Tangier, 90060, Tangier, Morocco.
| | - Saloua El Azzouzi
- Cardiac Surgery Department, University Hospital of Tangier, 90060, Tangier, Morocco
| | - Abdessamad Ait Brik
- Cardiology Department, University Hospital of Tangier, 90060, Tangier, Morocco
| | - Siham Alaoui
- Radiology Department, University Hospital of Tangier, 90060, Tangier, Morocco
| | - Mouhcine Madani
- Cardiac Surgery Department, University Hospital of Tangier, 90060, Tangier, Morocco
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Ozdemır O, Atalay CR. Transmediastinal Gunshot Wound in a Pregnant Patient with Stable Hemodynamics. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:145-147. [PMID: 33465788 PMCID: PMC10183918 DOI: 10.1055/s-0040-1715142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Transmediastinal gunshot wounds (TGWs) may lead to life-threatening injuries of vital organs such as large vessels, the esophagus, and lungs. Although they are not commonly encountered in pregnant women, additional caution should be given to these patients. Physical examination for the diagnosis and the choice of treatment modality contain controversial points in hemodynamically stable patients, and resuscitation has excessive importance due to physiological changes in pregnancy. We present a hemodynamically stable 26-week pregnant woman brought to the emergency department for TGW. She had a 1-cm diameter of bullet entrance hole on the right anterior 4th intercostal space, 2 cm lateral to the sternum, and a 3-cm diameter exit hole on the right posterior 12th intercostal space on the midscapular line. With our conservative approach, she had an uncomplicated pregnancy period, and gave birth to a healthy baby at term.
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Affiliation(s)
- Ozhan Ozdemır
- Department of Obstetrics and Gynecology, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Cemal Resat Atalay
- Department of Obstetrics and Gynecology, University of Health Sciences, Ministry of Health Ankara City Hospital, Ankara, Turkey
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Ahmad R, Bhatti DS, Bokhari MHT, Asad A. A University Hospital Based Study on Thoracic Trauma: Life Threatening Event, Its Etiology, Presentation, and Management. Cureus 2019; 11:e6306. [PMID: 31938598 PMCID: PMC6944145 DOI: 10.7759/cureus.6306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Thoracic injury is becoming an important cause of mortality in Pakistan, especially in the younger subset of population. The initial management of these injuries is essential as these patients can develop multiple complications, ultimately leading to death of the patients. MATERIALS AND METHODS This prospective observational study was carried out from January 2016 to December 2018 at the Department of Surgery, Holy Family Hospital, Rawalpindi Medical University, Pakistan. It included all the patients over 12 years of age who had thoracic trauma, who presented in the ED, and were admitted to the surgical ward and intensive care unit (ICU). Data were collected with the help of a pre-designed proforma. After relevant investigations and treatment, data were collected and analyzed through Statistical Package for Social Sciences (SPSS) for version 19. Nominal variables were reported as frequencies and percentages. RESULTS Out of a total of 330 patients, 188 (56.9%) suffered from blunt injuries whereas 142 (43%) had penetrating injuries. The most common cause of these injuries was road traffic accidents -- 105 (32%) followed by falls -- 23 (76%). Most of the injuries encountered were isolated pneumothorax -- 74 (22.4%) followed by rib fractures with pneumothorax -- 71 (21.5%). Tube thoracostomy was done in 189 cases (57.3%) whereas 94 (28.5%) patients were managed conservatively. Complications were seen in 117 patients (35.4%). Out of these 117 cases, death was the major complication - 30 (25.6%) followed by bronchopleural fistula - 24 (20.5%) and empyema thoracis - 22 (18.8%). CONCLUSION Road traffic accidents are a major cause of thoracic injuries in our setting. Tube thoracostomy is the most commonly used treatment modality. Mortality rate is high in the patients with thoracic injuries.
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Affiliation(s)
| | - Dujanah S Bhatti
- Plastic Surgery, Holy Family Hospital, Rawalpindi Medical College, Rawalpindi, PAK
| | | | - Ayesha Asad
- Anatomy, Quetta Institute of Medical Sciences, Quetta, PAK
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Femoral Embolization after Cardiac Gunshot. Case Rep Emerg Med 2018; 2018:7969845. [PMID: 30105103 PMCID: PMC6076973 DOI: 10.1155/2018/7969845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/19/2018] [Indexed: 11/17/2022] Open
Abstract
Bullet embolism is an uncommon complication from heart gunshot injuries because most of the patients die immediately after trauma. The low frequency of this complication combined with the possible absence of symptoms makes the condition a challenge for the surgeon, delaying diagnostics and leading to severe complications or death. In this case, a small calibre bullet entered the left ventricle and then impacted the femoris artery.
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Trauma to the heart: A review of presentation, diagnosis, and treatment. J Trauma Acute Care Surg 2017; 83:911-916. [DOI: 10.1097/ta.0000000000001667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fu HY, Ting M, Wang YC, Yu HY. Intracardiac foreign body resulting from a transmediastinal gunshot mimics an extracardiac foreign body: An image presentation. J Formos Med Assoc 2017; 116:815-818. [PMID: 28709823 DOI: 10.1016/j.jfma.2017.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/26/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022] Open
Abstract
A transmediastinal gunshot wound (TMGW) is one of the most severe traumatic injuries, with a high mortality rate. Prompt diagnosis and emergency surgical intervention with or without cardiopulmonary bypass are usually required to save lives. We report a particular case of TMGW in which the computed tomography imaging findings indicated an extracardiac foreign body. However, intraoperative findings revealed an intracardiac foreign body, and urgent cardiopulmonary bypass was performed to remove the foreign body. We suggest that cardiopulmonary bypass should be on standby during an exploratory sternotomy for TMGW, when the trajectory of the bullet hints at a cardiac-penetrating injury according to imaging studies and the location of the bullet remains unaffected by the patient's postural changes.
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Affiliation(s)
- Hsun-Yi Fu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Mao Ting
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan.
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Navsaria PH, Chowdhury S, Nicol AJ, Edu S, Naidoo N. Penetrating Trauma to the Mediastinal Vessels: a Taxing Injury. CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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11
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A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart. Case Rep Cardiol 2016; 2016:2427681. [PMID: 26977324 PMCID: PMC4764739 DOI: 10.1155/2016/2427681] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 11/18/2022] Open
Abstract
Penetrating cardiac trauma is rarely seen but when present there is a short time lag to keep the patients alive. Cardiac gunshot injuries are exceptional and it occurs mostly during interpersonal disagreements casualties or a mistakenly fired gun nowadays. Here we present a case of cardiac gunshot injury from the war of Kobani, Syria. The patient was mistakenly diagnosed to have a sole bullet in the left shoulder while he had a penetrating cardiac trauma with a bullet in the heart and pericardial effusion possibly giving rise to pericardial tamponade. Luckily the cardiac gunshot injury was noticed one day later and the patient was referred to a tertiary hospital. Intrapericardial bullet was conservatively followed up. The patient was discharged one week later after resection of the bullet in the shoulder.
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Okoye OT, Talving P, Teixeira PG, Chervonski M, Smith JA, Inaba K, Noguchi TT, Demetriades D. Transmediastinal gunshot wounds in a mature trauma centre: changing perspectives. Injury 2013; 44:1198-203. [PMID: 23298755 DOI: 10.1016/j.injury.2012.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/27/2012] [Accepted: 12/08/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Transmediastinal gunshot wounds are associated with a high mortality and frequently require operative intervention. The purpose of this study was to identify the diagnostic and therapeutic challenges of these injuries in a mature trauma system with decreasing prehospital time intervals. METHODS Patients admitted to a large urban Level 1 trauma centre between 1/2006 and 12/2010 sustaining a firearm injury to the torso were identified. Transmediastinal gunshot wounds were defined as missile tracts traversing the mediastinum identified on CT images, operative notes or autopsy reports. RESULTS Overall, 133 patients met study criteria. A total of 116 patients (87.2%) were haemodynamically unstable or had no vital signs on arrival to the Emergency Department. Ninety-seven (83.6%) of these patients required a resuscitative thoracotomy resulting in 8 survivors (6.0%). There were 17 haemodynamically stable patients (12.8%) identified, 14 of whom underwent CT scan evaluation. Six patients subsequently required operative intervention. Only 11 patients (8.3%) in the study population were successfully managed nonoperatively. The overall mortality was 78.9%, and for those who reached the hospital with vital signs, the mortality was 24.3%. CONCLUSIONS Transmediastinal gunshot wounds encountered in a mature trauma centre are highly lethal injuries requiring resuscitative thoracotomy in most instances. Changing perspectives in these injuries may reflect the effects of an evolving prehospital care.
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Affiliation(s)
- Obi T Okoye
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA 90033, United States
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Lema MK, Chalya PL, Mabula JB, Mahalu W. Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania. J Cardiothorac Surg 2011; 6:7. [PMID: 21244706 PMCID: PMC3033810 DOI: 10.1186/1749-8090-6-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 01/18/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chest injuries constitute a continuing challenge to the trauma or general surgeon practicing in developing countries. This study was conducted to outline the etiological spectrum, injury patterns and short term outcome of these injuries in our setting. PATIENTS AND METHODS This was a prospective study involving chest injury patients admitted to Bugando Medical Centre over a six-month period from November 2009 to April 2010 inclusive. RESULTS A total of 150 chest injury patients were studied. Males outnumbered females by a ratio of 3.8:1. Their ages ranged from 1 to 80 years (mean = 32.17 years). The majority of patients (72.7%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 50.7% of patients. Chest wall wounds, hemothorax and rib fractures were the most common type of injuries accounting for 30.0%, 21.3% and 20.7% respectively. Associated injuries were noted in 56.0% of patients and head/neck (33.3%) and musculoskeletal regions (26.7%) were commonly affected. The majority of patients (55.3%) were treated successfully with non-operative approach. Underwater seal drainage was performed in 39 patients (19.3%). One patient (0.7%) underwent thoracotomy due to hemopericardium. Thirty nine patients (26.0%) had complications of which wound sepsis (14.7%) and complications of long bone fractures (12.0%) were the most common complications. The mean LOS was 13.17 days and mortality rate was 3.3%. Using multivariate logistic regression analysis, associated injuries, the type of injury, trauma scores (ISS, RTS and PTS) were found to be significant predictors of the LOS (P < 0.001), whereas mortality was significantly associated with pre-morbid illness, associated injuries, trauma scores (ISS, RTS and PTS), the need for ICU admission and the presence of complications (P < 0.001). CONCLUSION Chest injuries resulting from RTCs remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce the incidence of chest injuries in this region.
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Affiliation(s)
- Monafisha K Lema
- Department of Surgery, Weill- Bugando University College of Health Sciences, Mwanza, Tanzania
| | - Phillipo L Chalya
- Department of Surgery, Weill- Bugando University College of Health Sciences, Mwanza, Tanzania
| | - Joseph B Mabula
- Department of Surgery, Weill- Bugando University College of Health Sciences, Mwanza, Tanzania
| | - William Mahalu
- Department of Surgery, Weill- Bugando University College of Health Sciences, Mwanza, Tanzania
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Cardiac air rifle pellet injury: a case report. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-010-0065-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Hartert M, Dahm M, Neufang A, Vahl CF. Minimum cause--maximum effect: the travelogue of a bullet. Interact Cardiovasc Thorac Surg 2010; 11:698-700. [PMID: 20709697 DOI: 10.1510/icvts.2010.245100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This case report involves a 57-year-old male, accidentally shot in the chest with a small bore firearm. The bullet entered the left hemithorax, disrupting the left internal mammarian artery. It then penetrated the anterior wall of the right ventricle causing a pericardial tamponade. After leaving the base of the right heart it perforated the diaphragm, the liver, the spleen and the pancreas. Finally, it penetrated the abdominal aorta 3 cm proximally to the coeliac trunk and reached its final position paravertebrally. This case report illustrates that the management of even minimum gunshot wounds requires a maximum variety of surgical skills.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010; 18:35. [PMID: 20565804 PMCID: PMC2898680 DOI: 10.1186/1757-7241-18-35] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Accepted: 06/17/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. RESULTS Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference. CONCLUSION The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.
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Affiliation(s)
- Philipp Lichte
- Department of Trauma Surgery, University Hospital of the RWTH Aachen, Aachen, Germany.
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Burack JH, Kandil E, Sawas A, O'Neill PA, Sclafani SJA, Lowery RC, Zenilman ME. Triage and Outcome of Patients with Mediastinal Penetrating Trauma. Ann Thorac Surg 2007; 83:377-82; discussion 382. [PMID: 17257952 DOI: 10.1016/j.athoracsur.2006.05.107] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 05/16/2006] [Accepted: 05/18/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). METHODS Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera. RESULTS Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. CONCLUSIONS In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.
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Affiliation(s)
- Joshua H Burack
- Department of Surgery, Kings County Hospital Center, and State University of New York-Downstate, Brooklyn, New York 11203, USA.
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18
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Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury 2007; 38:48-52. [PMID: 17054956 DOI: 10.1016/j.injury.2006.07.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 07/17/2006] [Accepted: 07/24/2006] [Indexed: 02/02/2023]
Abstract
AIM The purpose of this study was to review and evaluate the efficacy of contrast-enhanced helical computed tomographic (CT) scanning in evaluating potential mediastinal injuries in stable patients with transmediastinal gunshot wounds (TMGSWs). METHODS During the review period, 01 January 2002-31 May 2005, the medical records of all haemodynamically stable patients with TMGSWs were retrieved and reviewed for demographics, diagnostic workup, treatment and complications. Screening CT was considered inconclusive in the presence of a mediastinal haematoma, pneumomediastinum or a missile track in proximity of major mediastinal structures. Inconclusive CT scans were further evaluated with angiography, and/or oesophography, and/or cardiac ultrasound. RESULTS Fifty consecutive haemodynamically stable patients with TMGSWs were identified. Thirty-five CT scans were performed, of which 29 (82.9%) were conclusive. Further diagnostic evaluation in the remaining six patients showed no injury. All patients were observed in a high-care unit and there were no missed injuries. The hospital charges generated with the CT scan based protocol were significantly less than with standard evaluation. CONCLUSION Contrast enhanced helical CT scanning is a safe, efficient and cost effective screening tool for evaluating haemodynamically stable patients with TMGSWs.
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Affiliation(s)
- Sheriff Ibirogba
- Trauma Centre C-14, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
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Iwata T, Inoue K, Hige M, Yamazaki K, Kawata Y, Suehiro S. Multiple thoracoabdominal gunshot wounds with complicated trajectories. ACTA ACUST UNITED AC 2006; 54:444-7. [PMID: 17087326 DOI: 10.1007/s11748-006-0028-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A 41-year-old man was shot three times with a custom-made handgun. There were six small round wounds on the surface from two bullets that went into the body and one bullet found in a wall behind the victim at the scene. The gunshot wound in the left supraclavicular region bled massively. He was transferred to our hospital and soon fell into shock. A chest radiogram showed right hemothorax. Resuscitation and blood transfusion were started, and right thoracic drainage was immediately undertaken. The left subclavicular region was incised, and bleeding from the left subclavian vein stopped. Right thoracotomy was done, and bleeding from the lung was controlled. Laparotomy was needed to look for the missing trajectory. Speculation regarding trajectories of bullets in patients with multiple thoracoabdominal gunshot wounds is difficult, and an emergent operation is often needed to control bleeding or to evaluate possible organ injury.
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Affiliation(s)
- Takashi Iwata
- Department of Thoracic Surgery, Osaka City University Hospital, 1-4-3 Abeno-ku, Asahi-machi, Osaka 545-8585, Japan.
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Kadis P, Pogorevc L, Sipek M, Vidovic D. Unusual attempted suicide by shooting through heart. Forensic Sci Int 2005; 147 Suppl:S29-32. [PMID: 15694723 DOI: 10.1016/j.forsciint.2004.09.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Gunshot wounds in the heart are frequent suicidal injuries, especially in men. Most of them are lethal, but some cases of survival due to immediate and proper surgical treatment are reported. However, survival without specific treatment is extremely rare. In our case, a 44-year man attempted suicide by home-made shooting device. A special 12 cm long and 2.5 mm wide needle-like missile entered his body at the left anterior part of his chest, passed through the heart and lower lobe of right lung and exited at the right side of his back. The patient was able to move normally and he also looked for medical help immediately after attempting suicide. We found large atypical-shaped entrance wound on the anterior part of the chest, which was surgically treated, and tiny pointed exit wound under the right scapula. The patient was stable from cardio-circulatory and respiratory aspects from the time of admission to discharge from the hospital. We found only minimal pericardial bleeding (up to 10 mm thick) and there was no need for surgical intervention. In the next 2 weeks the haematoma absorbed spontaneously. The gunshot injury healed without any complication. Paranoid psychosis was diagnosed by psychiatrist and this probably had been the cause of attempting suicide. We think that the favorable outcome of the proved heart gunshot injury in our patient was due to the needle-shaped low-energy missile, which caused only tiny gunshot (stab) hole in the heart. Such a heart injury caused only minimal bleeding into the pericardial sac without heart tamponade.
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Affiliation(s)
- P Kadis
- General Hospital Slovenj Gradec, Surgical Department, Gosposvetska 3, SI-2380 Slovenj Gradec, Slovenia.
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