Thoracic gun shot wound

Case contributed by Dr Craig Hacking

Presentation

GSW to chest

Patient Data

Age: 25 years
Gender: Male
X-ray

There is a moderate to large right pneumothorax, with no mediastinal shift appreciated. There is also a wedge shaped peripherally based opacity within the collapsed mid to upper right lung. Heart size and mediastinal contours are normal.

There is a metallic, slightly irregular 9mm density projected within the superior mediastinum, immediately medial to the aortic arch. Smaller metallic fragments are also projected within the right mid to upper zone as well as over the lateral end of the right second rib. Moderate volume subcutaneous emphysema is present within the right supraclavicular fossa.

CT

There is gas in the anterior aspect of the right anterior chest wall and supraclavicular fossa. The right subclavian and axillary artery is intact. There is a dense radiopaque bullet fragment in the right supraclavicular fossa within a number of tiny fragments seen deeper to this but there is no trauma to the adjacent vessels.

There is at least one small radio opaque bullet fragment within the right upper lobe pulmonary parenchyma. The main mass of the bullet fragment measures 11 x 9 mm in size and is situated within the middle mediastinum, immediately posterior to the upper trachea and medial to the aortic arch. There is no post-traumatic aneurysm of the aortic arch or descending thoracic aorta.

There is a small amount of gas in the middle mediastinum which may have arisen from the the oesophagus given the location of the main bullet mass.

There is a large right-sided pneumothorax with considerable pulmonary contusion in the right upper lobe. The mediastinum is midline without evidence of tension. The left lung field is clear.

Conclusion

  • Large right-sided pneumothorax with bullet fragments in the right supraclavicular fossa region, the right upper lobe of the lung with the main bullet mass and the middle mediastinum just medial to the aortic arch.
  • The location of bullet fragment may have traversed the oesophagus which may account for a small amount of free gas in the middle mediastinum.

Case Discussion

Lucky to be alive!

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Case information

rID: 39344
Case created: 1st Sep 2015
Last edited: 27th Sep 2017
Systems: Chest, Vascular, Trauma
Tag: trauma
Inclusion in quiz mode: Included

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