Presentation
Gunshot wound chest.
Patient Data
Bullet fragment projects over the heart, otherwise normal exam.
Bullet fragments left groin, otherwise normal.
A radioopaque arrow marks the skin entry site. A bullet fragment projects over the heart, otherwise normal exam.
Minimal subcutaneous emphysema at skin entry site. Bullet fragment in right ventricle. Small hemopericardium.
Transesophageal echocardiogram probe. Bullet fragment again seen.
Right internal jugular catheter, mediastinal drain and right chest tube appropriately positioned. No pneumothorax. Interval median sternotomy and removal bullet fragment.
Case Discussion
The initial imaging (chest and pelvis X-rays) suggested the possibility that the bullet fragment embolized to the heart from a gunshot wound to the left groin, but the chest skin entry site seen on physical exam, the subcutaneous emphysema in the chest wall and the hemopericardium indicated that the bullet entered the heart directly through the chest wall. Pericardial and right ventricular defects confirmed and repaired at surgery.
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