Case #3: Bullet-ectomy ± proceed

The Patient*

A 30 year old male presented following multiple GSW to the neck, chest, and back. In total, there were nine wounds - two on the neck, two on the anterior left chest, one on the posterior right back, and two through the left upper arm.

Primary survey

A - Patent.

B - No oxygen requirement.

C - Mild haemodynamic instability (HR 73, NIBP 85/55) which responded to a crystalloid bolus. There were no hard signs of vascular injury in the neck, the CXR showed no haemothorax, and a FAST scan was negative for any free abdominal fluid - however, on LODOX a bullet was noted in the left lower quadrant of his abdomen - despite the absence of any abdominal wounds.

D - He was awake and alert with a GCS of 15. He had no motor or sensory function in his left upper limb or in either leg. He also had decreased anal tone.

Secondary survey

There was an obvious left humeral fracture, and the left leg was noted to be pulseless. Because of the triplegia, an assessment of sensory and motor function of the leg wasn't possible.

What is your next step?

• OT - for neck exploration and laparotomy.

• CT - to better delineate the nature of his injuries.

• MRI - to further investigate any spinal injury.

Click to see the answer

The patient underwent a split bolus CT "pan-scan" from neck to pelvis, and a CTA of the left arm. This demonstrated several findings of note:

• A transaxial GSW neck with left C3/4 transverse process fractures, a C4 anterior vertebral body fracture, and a right IJV injury, but no violation of the spinal canal.

• T9/10 spinous process fractures and a T10 vertebral body fracture with retropulsion of comminuted fracture fragments through the spinal canal at the level of T10. A pseudoaneurysm of the descending aorta was also noted at this level, with significant associated mediastinal haematoma.

• Small bilateral haemothoraces were noted that had previously been occult on CXR.

• No vascular injury of the left arm was identified.

• And finally, and perhaps most curiously, the bullet previously noted in the LLQ on LODOX was visible within the left common iliac artery along with some adjacent thrombus.

The patient's triplegia was felt to be due to the the T10-level complete cord injury superimposed on a left brachial plexus injury. The patient was kept in spinal precautions and the left arm was placed in a backslab pending orthopaedic review.

The bullet causing the spinal injury was felt to have also caused the aortic pseudoaneurysm but lost sufficient velocity that it was able to stop and be embolised, and the aortic injury was able to then self-seal.

Due to the trajectory across the posterior mediastinum there was also a concern for a possible thoracic oesophageal injury - as these are often occult on CT imaging. A gastroscopy was performed in the Resuscitation Room which demonstrated no injury.

After all of that, the patient continued to remain haemodynamically stable.

Which of the following is your next priority?

• Damage control laparotomy

• Neck exploration

• Aortic exploration

• Thoracic endovascular aortic repair

• Decompression and stabilisation of the T10 injury

• Iliac artery exploration

Click to see the answer

There's a lot going on to muddy the waters, but the patient had an acutely ischaemic limb - this is the surgical priority. The IJV injury could be managed conservatively, and the patient was haemodynamically stable and therefore did not require urgent exploration of his neck or his abdomen. The vertebral column injury was felt to be stable and able to be managed with a TLSO brace. The patient was taken for for common iliac artery exploration by the trauma service.

For access, the left hemicolon was mobilised, the retroperitoneum opened, and the iliac arteries exposed. After achieving proximal and distal control, the vessel was opened at the level of the CIA where the bullet was lodged, and the bullet then removed. We minimised handling of the bullet by metal instruments as much as possible, as this can affect subsequent forensic examination. The associated thrombus was then removed with a Fogarty catheter.

The vessel was inspected, and no injury was seen. The arteriotomy was then repaired with a prolene suture. Following the release of the vascular clamps, triphasic distal pulses were seen on Doppler.

The patient remained haemodynamically stable throughout the operation, and was discharged to the ICU where he stayed mechanically ventilated and continued to receive impulse control via a labetalol infusion. Two days later, he underwent TEVAR by the vascular surgeons (using the contralateral groin for access), and a 24x24x150mm stent was placed across the aortic pseudoaneurysm.

The patient was subsequently extubated and discharged from the ICU, and was able to begin his rehab.

*Note that patient details have been changed for the purposes of de-identification.

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Dr Devorah Wineberg is the deputy director of the trauma unit and co-ordinates the international doctors programme. She began her career as a paramedic before completing a BSc in physiology and subsequently her MBBCh at Wits, and later her Fellowship from the College of Surgeons. After first working as a general surgeon, she returned to her first love and completed her Certificate in Trauma and Critical Care. She is an ATLS and DSTC instructor and has interests in mass casualty and disaster management.

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