GSW to head causing pneumothorax?

[JPINFV]

http://www.blackwell-synergy.com/doi/full/...6.x?cookieSet=1

Case Report

Spontaneous expulsion of a bullet via the urethra

DALOKAY KILIÇ1Departments of 1Thoracic SurgeryDalokay Kılıçmd, Department of Thoracic Surgery, Başkent University Faculty of Medicine, Adana Teaching and Medical Research Center, Dadaloğlu Mah. 39. Sokak No 6, Yüreğir 01250 Adana, Turkey.

Email: dalokay7@hotmail.com, FERHAT KILINÇ22Urology, ALI EZER 33Surgery, Baskent University Faculty of Medicine, Adana Teaching and Medical Research Center, Adana, Turkey ANDSEZGIN GUVEL22UrologyDepartments of 1Thoracic Surgery, 2Urology and 3Surgery, Baskent University Faculty of Medicine, Adana Teaching and Medical Research Center, Adana, Turkey

Dalokay Kılıçmd, Department of Thoracic Surgery, Başkent University Faculty of Medicine, Adana Teaching and Medical Research Center, Dadaloğlu Mah. 39. Sokak No 6, Yüreğir 01250 Adana, Turkey.

Email: dalokay7@hotmail.com

Abstract

The rare clinical occurrence of the spontaneous passage of bullet which was not found during an operation after a gunshot wound to the bladder in a 28-year-old man is described.

Introduction

We report a new case of the spontaneous expulsion of a bullet after a gunshot wound to the bladder; an uncommon clinical entity. Bullets usually pass through rather than lodge in the bladder due to the thin wall and lack of resistance.

Case Report

A 28-year-old man presented to the Başkent University, Adana Teaching and Medical Research Center Emergency Department with penetrating gunshot wounds in his chest and pelvis caused by bullets from a pistol. The vital signs of the patient were unstable and emergency surgery was indicated. Physical examination revealed two entrance wounds, one in the left lateral part of the pectoralis major muscle and one in the left gluteal area. Plain X-rays of the chest and pelvis showed one bullet in the right hemithorax and one bullet in the pelvis (Fig. 1). An urethral catheter was inserted, and the urine was clear on gross inspection. Laboratory testing revealed hematocrit 25.2%, hemoglobin 8.4 g/dL and normal urinalysis. The patient was taken to the operating room immediately and underwent left thoracotomy-laparotomy.

Thoracotomy revealed damage to the parenchyma of the left lung, damaged segmental arteries in the superior lobe of the lung, and pneumohemothorax. All these problems were successfully repaired. The bullet was found in the right chest wall, but was left in place until the patient's condition stabilized. At laparotomy, there was no apparent injury to the abdominal organs or the bladder and the bullet detected on pelvic X-ray could not be found.

The patient's urethral catheter was withdrawn on the third day post-surgery and 2 h after removal he passed the 7.65-caliber bullet spontaneously during urination (Fig. 2). The patient was re-catheterized and cystography was performed. The bladder was filled with approximately 300 mL of contrast medium and a second X-ray was obtained after the contrast medium was removed via the catheter. There was no sign of bladder rupture on either film. The urethral catheter was withdrawn again and no further interventions were performed. The same caliber bullet in the right hemithorax was removed by mini-thoracotomy on the seventh day of hospitalization. The patient's postoperative course was otherwise uneventful, and he was discharged 10 days after the emergency surgery.

Discussion

Spontaneous voiding of a bullet after a gunshot wound to the bladder is rare. To our knowledge, there are only five published reports that describe spontaneous expulsion of an intravesical bullet via the urethra.15 Most gunshot wounds to the bladder are associated with injury to adjacent organs. Bullets may pass directly into the bladder with or without leakage of urine into the pelvis. The proposed explanations for this are the spontaneous healing of the bladder wall with rapid edema formation and immediate wound closure due to the elasticity of the bladder wall. In research on the canine bladder, Weyrauch and Peterfy showed that small puncture wounds of 0.1–0.2 cm in diameter result in no extravasation of urine.6 In the present case, a small-caliber bullet penetrated the patient's bladder with no apparent leakage of urine.

Physicians should be aware that with small-caliber gunshot wounds, when a bullet is detected on pelvic X-ray, but is not found on exploration, it might be inside the bladder. There may be no signs of bladder injury in these patients. In such cases, cystoscopy should be performed before discharge.

References

1 Sankari BR, Parra RO. Spontaneous voiding of a bullet after a gunshot wound to the bladder: case report. J. Trauma 1993; 35: 813–4.

Medline, ISI, CSA

2 Abdelsayed MA, Bissada NK, Finkbeiner AE, Redman JF. Spontaneous passage of bullet during voiding. South Med. J. 1978; 71: 83–4.

Medline, ISI

3 DiDomenico D, Guinan P, Sharifi R. Spontaneous expulsion of an intravesical bullet. J. Am. Osteopath. Assoc. 1997; 97: 415–6.

Medline

4 Cohen SP, Varma KR, Goldman SM. Spontaneous expulsion of intravesical bullet. Urology 1975; 3: 387–9.

CrossRef, Medline

5 Kyriakidis A, Karydis G, Papacharalambous A, Yannopoulos P. Spontaneous passage of shell fragments during voiding. Br. J. Urol. 1984; 3: 334.

Medline

6 Weyrauch HM, Peterfy RA Jr. Tests for leakage in the early diagnosis of the ruptured bladder. J. Urol. 1940; 44: 264–73.

[bbbrammer]

At 74 inches I would not have the tube at anything less than 21 cm. Spock

That is why I was not wanting to pull it out anymore from 21cm. At the time I got it to that depth the flight crew was on scene taking over pt care and I let them know what I had with the tube. Since he was their pt then, they took what they had and one of them helped me secure the tube where it was. Beyond that my resposibility (and assesment) of the pt was over, but in the gist of 'continuing education', I thought I would gather some opinions.

Most likely we will never know what happened, but it is usefull to toss the idea around anyway.

[als2170]

could be something real simple, like maybe he has hx of lung cancer etc, and thats why he shot himself.