A shot through the heart: a case report on retained bullet causing cardiac tamponade

Background: As a rare complication of penetrating chest trauma, one can occasionally find foreign bodies inside the pericardium. Even rarer is finding an intact bullet inside the pericardial cavity following the gunshot injury.

Case summary: A 17-year-old male presented to the emergency department as a Level 1 trauma for multiple gunshot wounds. Upon arrival, the patient was tachycardic but normotensive. Physical exam was notable for several penetrating wounds to the chest and right clavicle. The initial chest X-ray demonstrated a metallic foreign body consistent with a bullet overlying the cardiac silhouette. Approximately 24 h into the hospital course, ST-segment elevation was noted on telemetry. An electrocardiogram demonstrated sinus tachycardia with diffuse ST-segment elevation in all leads, consistent with acute pericarditis. Over the following several hours, the patient gradually developed tamponade physiology, prompting a more emergent median sternotomy.

Discussion: Although penetrating cardiac injury carries a high mortality rate, management of these patients and complications that may arise during their hospital course are rarely explained. The diagnosis of projectile chest trauma starts with history and physical examination. The primary diagnostic modalities are the X-ray, computed tomography scan of the chest, electrocardiogram, and echocardiogram. Management of a patient with cardiac gunshot depends largely on haemodynamic status. As in our case, a patient with haemodynamic instability is managed with emergency exploration and removal of the foreign body.