Expectoration of a bullet after gunshot wound to the chest.

Over the last century, only four cases have been published of patients sustaining gunshot wounds to the chest, managed nonoperatively, who eventually expectorated the bullet. We report the case of a hemodynamically stable 24-year-old male whose bullet was found in the left pulmonary hilum on admission computed tomography (CT) scan. Further workup revealed no obvious aerodigestive injury. Shortly after extubation, he expectorated the bullet onto the floor. Little is known about how to manage these stable, yet challenging patients.

INTRODUCTION

Spontaneous expectoration of a ballistic after penetrating trauma is a rare occurrence and as such has not frequently been detailed in the literature. We describe only the fifth patient in the last 100 years who sustained a gunshot wound to his chest and subsequently expectorated the bullet.

CASE REPORT

We report the case of a 24-year-old male who sustained a gunshot wound to his left shoulder. He presented to the emergency department with a primary complaint of shoulder pain and difficulty in swallowing. On primary survey, the airway was patent and he was hemodynamically stable. A single bullet wound was visualized above the left scapula. On chest radiograph, the bullet was located in the left pulmonary hilum near the mainstem bronchus [Figure 1]. No pneumothorax or hemothorax were apparent; this was confirmed with the radiologist. At this point, the patient complained of increasing difficulty in swallowing and was intubated for airway protection. An orogastric tube was passed erroneously into the airway precipitating vigorous coughing and eventual vomiting of gastric contents. Once this was properly replaced, the patient underwent CT angiography (CTA) of the chest and flexible bronchoscopy. CTA revealed no vascular injury; however, air was present throughout the mediastinum and the subcutaneous tissues of the anterior neck [Figure 2]. The bullet was again seen near the left mainstem bronchus [Figure 3]. There was no pneumothorax or hemothorax. After discussion with our radiologist, we believed that the bullet had likely caused a small airway injury which had quickly sealed, leading to the pneumomediastinum without evidence of pneumothorax or bronchopleural fistula. Flexible bronchoscopy revealed no blood or bullet fragments, but only a small abrasion in the left posterolateral trachea which was thought, at the time, to be due to trauma from the initial orogastric tube placement.

Figure 1

Chest X-ray

Figure 2

CT scan #1

Figure 3

CT scan #2

As no significant injuries were noted on initial bronchoscopy, the patient continued to be managed nonoperatively. In light of there being no pneumo- or hemothorax, the presumed trajectory of the bullet was from above the left scapula directly to the left pulmonary hilum. Based on this, it was felt that he was at low risk for esophageal injury, and gastrointestinal endoscopy was deferred. He remained intubated, afebrile, and hemodynamically stable. A second bronchoscopy by a thoracic surgeon was performed on hospital day 2 which again revealed only the small abrasion. He was extubated on day 3 and started on a regular diet. That night, the patient reported a ticklish sensation in the back of his throat and proceeded to sneeze, expectorating the bullet. Repeat chest radiograph confirmed that the bullet was no longer present in the chest.

DISCUSSION

To date, only four cases have been published of patients sustaining gunshot wounds to the chest, managed nonoperatively, who eventually expectorated the bullet. In each case, the patient presented with stable vital signs, one bullet wound, and a visible bullet in the chest on radiograph. Leslie[1] was the first to describe such a patient in 1917. The patient was found to have a bullet in the right chest, which he spontaneously expectorated after 4½ month of intermittent hemoptysis. He was subsequently discharged in good health having undergone no intervention. Andrews et al.[2] described a case similar to ours in which a bullet sustained in combat was found on radiograph to be adjacent to the right mainstem bronchus. On the way to the operating room for bronchoscopy, the patient coughed and expectorated the bullet. As in our case, bronchoscopy revealed a “sealed slit-like opening” along the anterior trachea. Hesami, et al.[3] reported a case of a bullet lodged near the tracheal bifurcation. This patient, although stable at presentation, did have a hemopneumothorax and tube thoracostomy was performed. The patient recovered well and was discharged home with the bullet still in place. Three months after the injury, the patient experienced a bout of coughing and expectorated the bullet. In a similar case, Saunders, et al.[4] reported a bullet lodged in the left hemithorax of a patient. Three months after injury, the patient developed hemoptysis and expectorated the intact bullet. Additionally, three cases have reported gunshot injuries to the head, neck, and chest in which the bullet lodged in the bronchial tree and was successfully removed bronchoscopically.[5-7]

At the time of initial evaluation of our patient, we struggled to determine the trajectory of the bullet as it passed through the left hemithorax. We presumed that its course was from just above the left scapula directly to the left pulmonary hilum. The lack of tracked air, pneumothorax, hemorrhage, and even pulmonary contusion made this very difficult to determine, however, and lead to the conclusion that the trachea was not involved. Retrospectively, it seems more plausible that the bullet initially penetrated the trachea and was aspirated into the smaller airways. The small caliber of the bullet—determined by our detectives to be likely a. 22 or. 25 caliber—contributed to the rapid sealing of his tracheal defect and its appearance as a simple abrasion. Furthermore, there was a known erroneous passage of the orogastric tube into the airway during his initial resuscitation, which lent credence to our hypothesis. We believe that after extubation, the patient was able to produce a strong cough allowing the bullet to migrate proximally and ultimately be expelled.

Most literature on the management of foreign body aspiration focuses on accidental aspiration, primarily by children. The general principles of airway safety and foreign body identification and, if possible, extraction pertain to both our patient as well as the accidental aspiration. However, the findings of two bronchoscopic evaluations convinced us that there were no intraluminal foreign bodies, leading us to extubate the patient.

In the patient with a gunshot wound to the neck or upper chest, the classic teaching is to rule out major vascular and aerodigestive injury using a combination of CT imaging or angiography and bronchoscopy/endoscopy. Identification of such injuries takes us down relatively well-established care pathways which lead to either the operating room or endovascular suite. The real question is what to do when we identify minor or no injuries in the stable patient with a neck/thoracic gunshot wound. The idea of using CT imaging to establish bullet trajectory and proximity to vital structures and to determine need for invasive procedures has been validated by several large-volume trauma centers in the US. Gracias et al.[8] reviewed their series of 23 hemodynamically stable patients with penetrating neck injury who underwent CT scan of the neck. They found that CT scan effectively ruled out trajectories consistent with aerodigestive or vascular injuries in 13 of the 23 patients. Only 2 patients required endoscopy due to proximity of penetrating injury detected on CT, and no patient suffered an adverse event due to physiologic deterioration. Taking this one step further, Hanpeter et al.[9] used high-resolution CT to determine missile trajectory in 24 patients with transmediastinal gunshot wounds. They concluded that CT scan accurately identified patients who needed further invasive studies, such as angiography and endoscopy. As we see more of these types of patients, especially from our military counterparts, it will be necessary to develop algorithms for managing these stable, yet challenging patients. There is mounting evidence that high-resolution CT and CT angiography should play a key role in determining which of these patients require more costly and invasive studies to rule out clinically significant injuries.