A 19-year-old man sustained a gunshot to the suprasternal notch with no exit wound. The precise make and model of the weapon were unknown (A).He presented to the emergency department with severe thoracoabdominal pain that was relieved spontaneously. The patient was hemodynamically stable during admission, with a Glasgow Coma Scale score of 15. Initial vital signs were as follows: mean blood pressure, 100 mm Hg; heart rate, 105 beats/min; peripheral oxygen saturation, 96%. He underwent chest radiography, which showed a small mediastinal hematoma and pleural effusion (B); chest drainage was subsequently performed (200 mL of serosanguineous fluid). On examination, he had paresthesia and pallor but no pain on the left lower limb. The distal pulses (popliteal, pedal, and tibial) were not present. A plain radiograph of the extremity was performed, revealing the bullet’s location (C). The patient was taken to the operating room 12 hours after the injury for a transverse arteriotomy, surgical removal of the bullet, and thrombectomy (D). Intra-arterial heparinization was performed. The patient's postprocedure course was favorable, with complete recovery of all symptoms. He was evaluated on postoperative day 7 by computed tomography angiography, which demonstrated no sign of pseudoaneurysm. Informed consent was obtained from the patient for the publication of this case.
Discussion
The first bullet embolism was described by Thomas Davis in 1834. Adegboyega et al in 1996 reported only 160 cases of bullet embolism since 1834. There are two prerequisites for a bullet embolism: the bullet must have very little kinetic energy at the moment it enters the blood vessel, and the diameter of the blood vessel must exceed that of the bullet. Bullet embolism to the peripheral arterial system is an extremely rare phenomenon that frequently results in misdiagnosis because of lack of early symptoms. The signs of acute arterial occlusion should always be evaluated; paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis are important to determine the duration of the ischemia and prognosis through the Rutherford classification. It is important to consider the possibility of a bullet embolism when entry and exit wounds are discordant. Once it is diagnosed, the projectile should be removed as soon as possible even if the patient is initially asymptomatic as the embolus might eventually become symptomatic with possibly severe consequences.