GSW TO RIGHT CHEST. WHAT IS THE WORKUP OF THIS CASE

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My image viewer is terrible.

There may or may not be a bullet in the right chest. 
If what I'm seeing is a bullet, it's crazy medial,
maybe into the cardiac sillhouette.  

If that's NOT a bullet: I'd get a wide abdominal view
to see if there's a bullet in the belly (if you see
the bullet, the algorithm is simple).  Tube into the
right chest.  If he becomes unstable and output is
high, thoracotomy possible laparotomy (blood may well
be coming up from the belly).  If he becomes unstable
and your chest tube output is low, laparotomy,
possible thoracotomy.    

If that IS a bullet:  Put a tube into the right chest
and see how much comes out, get a lateral chest x ray
and see whether the bullet lies posterior or anterior
or where ever.  But keep in mind that if he crumps for
ANY reason the default assumption is that this likely
represents a mediastinal injury and the decompensation
warrants pericardial exploration (and esophageal and
airway).  The choice for thoracotomy versus median
sternotomy depends on the surgeon's confidence.    

Ben Reynolds, PA-C
Pittsburgh, PA  
--- SJASMD at aol.com wrote:

> We seem to be having a run of interesting gunshot
> wounds of the chest at  our 
> hospital. I have been in disagreement with the
> management of many of them  
> and look to this site to give me a reality check.
> Here is another chest  case.
>  
> This case is a 35 year old male who sustained a
> single gunshot wound of the  
> right chest posterolaterally with no exit wound. He
> presented alert, but  
> short of breath . On exam he was normotensive and
> diminished breath  sounds in the 
> right chest.. There was an entry wound in the
> postero lateral area  of his 
> right thorax around the seventh intercostal space.
> but no exit  wound.
>  
> He was sent for a chest xray which i share with you.
>  
> next step?
>  
> sal 
> 
> 
> 
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