Tommy Brown, II
Massachusetts General Hospital
Boston, Massachusetts, United States
Disclosure information not submitted.
Alan Marr, MD FACS
Professor of Clinical Surgery
LSUHSC Department of Surgery
New Orleans, Louisiana, United States
Disclosure information not submitted.
Lance Stuke, MD MPH FACS
Professor of Clinical Surgery
LSUHSC Department of Surgery
New Orleans, Louisiana, United States
Disclosure information not submitted.
Patrick Greiffenstein, MD
Assistant Professor of Clinical Surgery
LSUHSC Department of Surgery
New Orleans, Louisiana, United States
Disclosure information not submitted.
Alison Smith, MD PHD
Assistant Professor of Clinical Surgery
LSUHSC Department of Surgery
New Orleans, Louisiana, United States
Disclosure information not submitted.
John Hunt, MD MPH FACS
Endowed Professor of Trauma Surgery and Anesthesia
LSUHSC Department of Surgery, United States
Disclosure information not submitted.
Title: ECMO and the Vanishing Bullet: Case Report of a Bullet Embolus to the Pulmonary Artery
Case Report Body:
Introduction: Pulmonary artery bullet embolism is a rare complication following gunshot wounds (GSWs) & creates unique challenges. Reviews show ~0.3% embolus rate - most being central to peripheral. Around 33% are venous & 200 reports involved the pulmonary arteries. Extracorporeal membrane oxygenation (ECMO) is an emerging treatment of severe ARDS in trauma patients with early cannulation likely improving mortality. We present a 22-year-old male with a left pulmonary artery bullet embolus complicated by post-operative ARDS & ECMO cannulation.
Description: The patient is a 22-year-old with multiple GSWs to the right chest & abdomen with a stable blood pressure. He underwent CT scan showing a grade 4 liver injury extending to the IVC & a left hilar bullet without a clear tract. He was taken to the OR for exploration. A pericardial window & EGD found no injuries. A left thoracotomy revealed a ballistic fragment palpable in the pulmonary artery. This was left & endovascular retrieval planned. After resuscitation, endovascular retrieval via the femoral vessels was considered. However, size mismatch between the bullet fragment (14mm) & bilateral iliac veins (11mm) precluded endovascular retrieval. On hospital day (HD) 4, a left thoracotomy open retrieval was performed. After tolerating single lung ventilation and hilar vessel isolation, the bullet was removed. An additional large clot burden was noted. Post-operatively, he had significant respiratory issues & was unable to be weaned. The following morning, a Murray Score of 3 was obtained & the ECMO team was consulted with subsequent cannulation. He was able to be successfully decannulated on HD 13. His total time on circuit was 8 days.
Discussion: Bullet embolus in general is rare (about 0.3% of retained bullets), pulmonary artery embolus represents only ~200 of described cases & can present a unique challenge for the trauma surgeon. Due to the rarity of such cases, no guidelines currently exist. Endovascular retrieval has recently become the preferred retrieval choice. However, it is not always a feasible option & open retrieval is required. Additionally, ECMO is emerging as a viable option for polytrauma patients who develop resultant ARDS.