MIGRATING BULLET PULMONARY EMBOLUS: A CASE OF DIAGNOSTIC AND THERAPEUTIC CHALLENGES

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gunshot wounds resulting in vascular injuries are common trauma patients, however, bullet embolism is quite rare. There no ideal treatment for pulmonary as each case unique. Proposed algorithms have advocated management based on symptomatology and accessibility of the bullet. We present our experience with a artery embolus its associated diagnostic therapeutic challenges. CASE PRESENTATION: A 23-year-old man sustained gunshots to torso all extremities. He was hemorrhagic shock, dyspneic, had several slugs scattered throughout his clothing. Radiographs showed projectiles left hemithorax (Figure 1), abdomen pelvis. Examination revealed penetrating thorax. underwent exploratory laparotomy ligation right iliac vein injuries. Postoperative CT demonstrated what appeared be projectile bronchus 2). Chest x-ray following day suggested migrated hemithorax. It presumed that initially bronchus, then displaced into bronchial tree patient repositioning. Bronchoscopy failed locate projectile, raising suspicion it not airways. angiogram confirmed arterial tree. Interventional Radiology attempted retrieval from lower lobar but unsuccessful 3). Surgical extraction via posterolateral thoracotomy attempted. While gaining proximal control artery, dislodged aborted. To prevent further migration, performed embolization within branch artery. DISCUSSION: Pulmonary emboli very Symptomatology variable, fragment size, location Cases aspirated bullets been reported limited face/neck gunshot wounds. Our did any such initial imaging suggestive endobronchial bullet, which presented challenge. Once confirmed, various attempts were made. In hindsight, likely would done well if place. This highlights importance multidisciplinary approach unusual injury patterns, early diagnosis may avoid unnecessary interventions. CONCLUSIONS: Ballistic intrathoracic foreign body without physical evidence thoracic penetration cases asymptomatic where feasible, this segment considered migration. REFERENCE #1: Mattox KL, Beall AC Jr, Ennix CL, DeBakey ME. Intravascular migratory bullets. Am J Surg 1979;137:192–5. #2: Mutafchiyski VM, Popivanov GI, Shopov ID, Iordanov HA. single wound face simultaneous aspiration ingestion two R Army Med Corps. 2015 Mar;161(1):67-8. #3: Agarwal SK, Singh A, Kathuria M, Ghosh PK. Wandering embolizing artery: report. Asian Cardiovascular Thoracic Annals 2007;15(April (2)):154–6. DISCLOSURES: No relevant relationships by Joseph Carroll, source=Web Response Geoffrey Douglas, Carmen Flores, Lance Horner, Arthur Oliver Romero,