Pulmonary haemorrhage from gun-shot wound

Case contributed by RMH Core Conditions

Presentation

Gun shot wound in right shoulder

Patient Data

Age: 22
Gender: Male
X-ray

Chest

There is extensive shrapnel projecting over both the right and left hemithoraces, right sided subcutaneous emphysema, opacification of the right hemithorax, with some basal lucency, suspicious for right haemopneumothorax. Multiple right sided rib fractures. The mediastinum is slightly deviated to the left side. ETT projects appropriately, right pneumocath noted.

Gunshot wound to the chest. The bullet tract begins at the right arm and axilla and extends through the posterior lateral right thoracic cavity and runs into the soft tissues of the back, where it then runs into the left back where the main bullet fragment is lodged posterior to the left scapula.

The right axilla demonstrates subcutaneous emphysema and stranding of the soft tissue consistent with haemorrhage.

The right subclavian artery and vein do not demonstrate any evidence of injury.

There is associated severe comminuted right scapular infraspinatus fossa fracture with multiple bullet fragments surrounding the fracture. The tract then runs into the right thoracic cavity with comminuted fractures of the sixth rib, seventh rib and eighth rib, with multiple bullet fragments adjacent to them. The nature of the fractures does raise the possibility of a flail segment. 

The superior and posterior basal segments of the right lower lobe and the posterior segment and posterior portion of the apical segment of the right upper lobe display dense consolidation consistent with haemorrhage. The superior segment of the right lower lobe also contains shrapnel and several traumatic pneumatocoeles, the largest of which measures 2 x 1.3 cm is size.

Right anterobasal pneumothorax. Right posterobasal haemothorax. A right ICC is present but lies within the horizontal fissure. A smaller catheter lies coiled in the right pectoral muscles.

Multiple bullet fragments are noted in the right posterior costophrenic angle with no evidence of having breached the diaphragm. The main bullet tract exits the right posterior thoracic cavity and enters the soft tissues of the back with multiple bullet fragments present and subcutaneous emphysema. The bullet tract extends through to the tip of the body of the left scapula which has a comminuted fracture. The main bullet fragment lies posterior to the left scapula. The left lung is clear with no evidence of injury. The heart is normal with no evidence injury present, no pericardial effusion and no mediastinal haematoma. The aorta is normal. NG tube and ETT tube present.

Case Discussion

Gunshot wounds require special attention because bullets and shrapnel can widely ricochet, damaging structures distant from the entry wound. 

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Case information

rID: 27928
Case created: 27th Feb 2014
Last edited: 13th Mar 2016
Systems: Chest, Trauma
Inclusion in quiz mode: Included

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