A Lethal Cardiac Injury Inflicted by a Nonlethal Weapon.

Dear Editor,

A 15-year-old male patient was admitted 26-min after having been inadvertently shot by his brother. He was shot at a close range while playing with an air rifle. On admission: The patient was unconscious and cyanotic. Physical examination revealed Beck's triad [Figure 1]. Radial pulse and BP were not palpable. The entry wound was 0.4 cm in diameter located over the sternum at the level of 5thcostal cartilage. Emergency department thoracotomy with pericardiotomy was performed. Cardiac tamponade was resolved. A 0.4 mm defect was found in the right atrial wall which was repaired with nonabsorbable suture. The patient developed acute kidney injury, and subsequently multiorgan dysfunction. On the second postoperative day, the patient died.

Figure 1

Patient with 0.4 cm pellet gun wound over the sternum, cyanosis, and jugular vein distention

Even though air guns and rifles are considered nonlethal or less-lethal weapons, they can inflict life-threatening injuries, especially when used at a close range. The mechanism of propulsive power in air weapons is sudden decompression of a compressed gas.[1] Muzzle velocity of air weapons may vary from 60 to 380 mm/s depending on the power source and mechanism.[2] However, despite air weapons are nonlethal, their muzzle velocity often exceeds the velocity required to penetrate eye (39 m/s),[3] skin (38–70 m/s),[4] and bone (106 m/s).[5] Moreover, given lower temperatures produced by pellets as compared to powdered weapon projectiles, injuries caused by them have a higher preponderance for bacterial contamination. Several cardiac injuries inflicted by air weapons have been reported so far. The tragedy with air guns, in particular, is that the highest rate is observed in the age range of 10–14 years (48.4 in 100,000) and 66% of those injuries are unintentional.[6] McNeill and Annest reported the composite rate of air weapon injury in boys aged 1–14 to be 121.1/100,000 population a year.[7]

Clinical presentation, complications, and outcomes of cardiac injuries caused by air weapons vary from a stable patient with dysrhythmia from an intrapericardial pellet[8] to cardiac tamponade causing death shortly.[9] Emergency thoracic exploration is warranted when the patient presents with Beck's triad or massive bleeding with the rate >200 ml/h. Cardiac tamponade even requires emergency department thoracotomy as even a minute delay may be fatal.

To conclude, surgeons, emergency room physicians, and other specialists should be aware that injuries inflicted by nonlethal weapons, namely air weapons may be serious, even lethal.

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