Fw: GSW Where did that come from

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Sorry, hit send to soon, here it is in full.



25 year old male arrive by EMS with multiple, presumed small caliber GSW's.

Awake and talking in ER on arrival.

Wounds as noted:

Left lateral canthus with dilated/fixed left pupil
Right facial cheek
Left forarm (intact pulses)
Left hip at about the pelvic crest
Left posterior region just above the pelvic crest

Blood in airway, suctioned, sedated, paralyzed, intubated
BP 150/80 Pulse 80-100

Lungs clear and equal

Abdomen soft

Foley with microscopic hematuria, no gross blood.

FAST negative

Portable CXR shows to pristine bullets, 1 overlying the area of the arch, 1 at level of diaphragm in midline

Portable abdomen/pelvis shows 2 flattened fragments at level of pelvic crest.

Lateral portable CXR shows 1 intact bullet anterior to sternum, the other in between the 2 diaphragm (right/left) shadows

CT done but on the older backup scanner as GE Lightspeed was broken.

No intracranial fragments or injury, globe intact.

Images not the greatest, shows the superior chest bullet laying anterior to sternum in dense adipose tissue, lower thoracic bullet is still difficult to accurately place, ?IVC, ? soft tissue, ?liver ( I am trying to get images to share)

Abdomen CT shows a damaged left lower kidney pole but rest still enhances and ureter intact

Echocardiogram shows no developing effusion and no bullet in chambers, good cardiac parameters by echo.

All time in ED remained hemodynamically stable and rarely tachycardic.  Admitted to ICU with general surgery, cardiothoracic, ortho (forearm fracture from bullet), ENT (for facial) and ophthalmo for eye.

Hopefully will re-CT once better scanner is up.

I suggested that perhaps the lower thoracic bullet could be a venous migration but cannot figure out where upper, sternal bullet came from.  Denies prior GSW.  No truncal wounds at all.  CT showed no pneumo or track.

Will try to get some representative images this weekend.

Any thoughts until then?

Andrew Bowman, RN, etc, etc

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