We report a case of a 42-year-old male patient who was transferred to our emergency department suffering from a gunshot wound in his left lateral thigh. The patient was haemodynamically stable, and the physical examination of the abdomen and thorax was unremarkable. There was no obvious exit point and there were no other injuries. The radiologic control of the left thigh showed an intact femur and multiple pellets within the adjacent soft tissues. Routine X-ray evaluation of the thorax revealed a small-sized round object of metal density—possibly a migrated pellet—in the proximity of the right heart atrium. Computed tomography imaging confirmed this finding and showed no other cardiac or mediastinal injury. Ultrasonography of the heart was unremarkable as well. The patient was managed conservatively for the discovered pellet, and remained asymptomatic throughout the entire hospital stay, and 6 months after the discharge. Pellet migration or embolism should be suspected in any gunshot victim without a corresponding exit wound or when the signs and symptoms do not correlate with the suspected course of the missile. Conservative management remains the first choice in asymptomatic patients, although close monitoring at first and regular observation after discharge are indicated.
Penetrating gunshot wounds of the thorax remain a major surgical challenge and show a high incidence, especially in warzones and societies with increasing crime rates [
A 42-year-old male was transferred to our emergency department having been shot with a hunter’s rifle in his left lower thigh. The patient was haemodynamically stable (Blood Pressure: 140/80 mm Hg; Heart Rate: 95/min; SO2: 100%; Glasgow scale: 15/15). The physical examination revealed an open wound (almost 10 cm × 6 cm in size) at the lateral side of his left thigh, with multiple pellets visible inside and around the wound. There were no other visible injuries. The auscultation of the thorax did not reveal any abnormal respiratory or cardiac sounds. The abdominal examination revealed no sensitivity or abnormal bowel sounds. There was significant tissue damage (mainly subcutaneous and muscular tissues) at the entry point, without any visible exit point and without injury of major vascular structures. There were no signs of ischemia or neurological deficits at the time. The medical history of the patient was unremarkable as well.
The laboratory findings revealed leucocytosis (WBC: 14,700; NEU: 81%), anaemia (HCT: 33%; MCV: 83.9 fL), and a normal platelet number (PLT: 222,000). The remaining laboratory studies were as follows: glucose: 120 mg/dL; urea: 19.6 mg/dL; creatinine: 0.73 mg/dL; CPK: 10,900 U/L; K+: 3.83 mmol/l; Na+: 132 mmol/l. Clotting times were normal as well. The patient received intravenous fluids, prophylaxis against tetanus, wide spectrum antibiotics (cefuroxime and clindamycin i.v.), antithrombotic prophylaxis, and adequate analgesia.
The radiologic control of the left thigh showed an intact femur and multiple pellets inside the adjacent soft tissues (Figure
X-ray of the left femoral bone. Multiple pellets are visible in the surrounding soft tissues. No bone fracture.
X-ray of the thorax. A small-sized round object of metal density (pellet) lies in the proximity of the right atrium.
Computed tomography (CT) of the thorax. A small-sized metallic artifact lies at the opening of the right atrium of the heart. No other cardiac or mediastinal injury.
The patient underwent surgical debridement of the wound, where multiple pellets were removed and adjacent soft tissues were explored. Conservative management with antibiotics and serial scanning to monitor further bullet migration was favoured over surgical extraction of the intracardiac pellet. This decision was based on the patient being asymptomatic, the pellet being on the right side of the heart, and clinical experience of previous similar cases. After consulting with a cardiac surgeon as well, the patient was admitted into our surgical department for further observation and monitoring.
The patient remained asymptomatic throughout the admission and was discharged after 5 days. Out-patient reevaluation with X-rays at 6 weeks and 6 months after discharge showed that the pellet remained at the same location. The patient remains stable after 6 months and without history of embolic events.
Since the first documented case by Davis in 1834, many cases of foreign body embolization have been described, with bullets accounting only for 0.3% of the responsible artifacts [
There are usually no clear symptoms or signs from migration of a bullet. Venous emboli are often an occult phenomenon and may remain unrecognised until migration leads to vascular injury or flow obstruction [
Traumatic foreign objects invade the vasculature via direct propulsion into the lumen or erosion into the vessel wall [
Regarding management, surgical intervention for the treatment of symptomatic patients has been clear so far. Reasons for removal of intracardiac pellets include avoidance of major venous obstruction, endocarditis, arrhythmias, myocardial irritability, valvular dysfunction, and delayed migration [
Asymptomatic lung emboli, however, do not usually lead to serious sequelae [
Our patient was successfully treated with observation and without any intervention. Other authors support the conservative management as well [
Pellet migration or embolism should be suspected in any patient who has a gunshot wound without a corresponding exit wound, when the signs and symptoms do not correlate with those expected from the suspected course of the missile or when radiologic studies show that missile location is deviating from the path of penetration. Conservative management remains the first choice in asymptomatic patients with migrating pellets to the heart, although close monitoring at first and regular observation after discharge are indicated.
The authors declare that there is no conflict of interests regarding the publication of this paper.