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J Chest Surg 2024; 57(1): 87-91
Published online January 5, 2024 https://doi.org/10.5090/jcs.23.061
Copyright © Journal of Chest Surgery.
Seonyeong Heo , M.D., Jung Hee Kim
, M.D., Younggi Jung
, M.D., Ph.D., Kwanghyoung Lee
, M.D., Sungho Lee
, M.D., Ph.D., Eunjue Yi
, M.D., Ph.D.
Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
Correspondence to:Eunjue Yi
Tel 82-2-920-5436
Fax 82-2-920-5369
E-mail viking99@hanmail.net
ORCID
https://orcid.org/0000-0002-2403-6839
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gunshot-induced chest trauma is exceedingly rare among civilians in South Korea due to strong firearm control policies. In contrast to military reports emphasizing the use of emergent open thoracotomy to increase chances of survival, most penetrating non-cardiac injuries in civilian settings are managed conservatively, such as through chest tube insertion, as they typically result from lower-energy bullets. However, early surgical intervention for penetrating gunshot wounds can help reduce delayed fatalities caused by septic complications from pneumonia or empyema. The advent of minimally invasive thoracic surgery has provided cost-effective and relatively non-invasive treatment options, aided in the prevention of potential complications from undrained hematomas, and facilitated functional recovery and reintegration into society. We successfully treated a patient with a penetrating gunshot wound to the chest using video-assisted thoracoscopic surgery.
Keywords: Penetrating wounds, Video-assisted thoracic surgery, Case report
A 15-year-old male patient was admitted to the emergency room of Korea University Anam Hospital due to chest trauma. He was a shooting athlete who had accidentally been shot with a .22 caliber pistol during training. Upon arrival, his initial systolic blood pressure was 97 mm Hg, and his heart rate was 118 beats per minute. We observed a small wound (approximately 5 mm) on his left back, as well as a slightly larger wound in the upper left anterior chest wall. After securing the patient’s airway through intubation and initiating rapid transfusion via a central catheter inserted into the right jugular vein, we conducted an imaging study. An initial chest radiograph revealed a massive hemorrhage in the left thoracic cavity (Fig. 1A). A follow-up radiograph taken 30 minutes after arrival, along with chest computed tomography (CT) scans, showed an increasingly massive hematoma and a heart skewed to the right (Fig. 1B–D).
The patient was immediately taken to the operating room for exploration via video-assisted thoracoscopic surgery (VATS). General anesthesia was administered, and a double-lumen endotracheal intubation was performed. Upon thoracoscopic examination, a large quantity of fresh blood clots and bloody effusion was discovered. After the hematoma was evacuated, a wound of approximately 5 mm, potentially an entry wound, was identified at the 10th intercostal space (Fig. 2A). A penetrating track was also found, extending from the posterior to the anterior basal segment of the left lower lobe (Fig. 2B, C). The lingular segment of the left upper lobe exhibited a short bullet pathway (Fig. 2D, E), which was connected to a hole in the sixth intercostal space of the anterior chest wall (Fig. 2F). Due to continuous bleeding, the wound in the lingular segment and anterior basal segment were resected using a surgical stapler (Echelon Flex Powered 60 Endopath Stapler; Ethicon Inc., Somerville, NJ, USA). A tractotomy was not performed.
Following surgery, the patient was moved to the intensive care unit (ICU) while still under sedation and intubation. The day after surgery, extubation was performed, and the patient was moved to the general ward. Two chest tubes were inserted, along with 1 drain tube, which was inserted through the extraction wound on the anterior chest wall at the level of the fourth anterior intercostal space (Fig. 3A). The entry wound on the posterior chest wall was sutured (Fig. 3B). No hematoma was observed on the immediate postoperative chest radiograph (Fig. 3C) or in follow-up prior to discharge (Fig. 3D).
The chest tubes were removed 18 days after surgery due to a continuous air leak, and the patient was discharged on postoperative day 21. Follow-up chest CT scans were conducted 1 week and 1 month after surgery to monitor the resolution of any remaining hematoma and to detect potential complications. No permanent cavities caused by the trajectory or parenchymal damage were observed on a chest X-ray taken 33 months after the procedure. A subsequent chest CT scan was scheduled 2 years post-injury to identify any potential lingering complications.
This study was approved by the Institutional Review Board of Korea University Anam Hospital (IRB number: 2021AN0526). The patient and patient’s caregiver provided written informed consent for publication of the research details and clinical images.
Penetrating chest injuries caused by firearms frequently present complex challenges for healthcare providers, particularly if providers lack experience with such conditions. Previous studies have indicated that penetrating thoracic gunshot wounds in civilian settings can often be managed non-operatively, as they are typically associated with low-velocity bullets. This contrasts with injuries sustained in military incidents, which are usually caused by high-velocity missiles or shrapnel and often necessitate immediate open thoracotomy [1-3]. Immediate surgical intervention should be considered if the patient is in shock (systolic blood pressure <70 mm Hg), if the initial chest tube drainage exceeds 1,500 mL, if continuous hourly drainage surpasses 150 to 200 mL, or if injuries to mediastinal structures are suspected [1,4-6]. Non-cardiac penetrating chest trauma that does not present with symptoms of shock often does not require surgical intervention [1,3].
Upon initial physical examination, we identified an entry mark and wound on the patient’s chest wall. The patient’s blood pressure indicated that he was not in a state of shock. With rapid transfusion, his systolic blood pressure was maintained at over 70 mm Hg, and heart rate was kept under 120 beats per minute. Chest CT scans revealed no major injuries to the mediastinal structures. However, rather than opting for chest tube insertion and close observation through conservative management, we decided to proceed with immediate surgical intervention.
Several factors informed this decision. First, serial chest radiographs revealed increasing radiopacity in the left lung field (Fig. 1A, B), suggesting the possibility of ongoing bleeding. The chest CT scans displayed a substantial hematoma in the left thoracic cavity, with a rightward displacement of the heart (Fig. 1C, D). While chest tube insertion and ICU monitoring could alleviate the symptoms, there are only temporary solutions, particularly when specific injuries necessitate bleeding control.
The patient’s systolic blood pressure was maintained above 90 mm Hg through the rapid transfusion of five 400-mm packs of red blood cells and intravenous fluid resuscitation. Despite follow-up imaging studies revealing an increase in haziness in the left thoracic cavity, the mediastinal shift had not extensively deteriorated, leading us to suspect a decrease in bleeding rate. The entry and exit wound were of similar, size, suggesting that the bullet had not tumbled within the pulmonary parenchyma, and likely did not cause substantial damage. Upon examination of the chest CT, we found no signs of serious damage to major structures, including the pulmonary vessels, bronchus, and intercostal arteries.
The VATS procedure is considered a safe and affordable option that does not put patients at risk. In this case, it could also aid in achieving appropriate surgical management, including controlling the source of bleeding with minimal additional injury. Given that the patient was a promising 15-year-old athlete, preserving thoracic muscle strength and minimizing the surgical wound were considered beneficial, provided the patient’s condition remained stable. Isolated pulmonary gunshot trauma can substantially alter pulmonary function and respiratory muscle strength [7], so it was preferable to avoid potential additional damage caused by an open thoracotomy.
We posit that conservative management, which includes chest tube drainage, may be insufficient to eliminate a massive hemorrhage, even in the absence of ongoing bleeding injuries. Undrained hematomas can lead to delayed complications such as empyema, which may necessitate extensive surgical intervention, extended ICU care and hospitalization, delayed functional recovery, and, in rare cases, sepsis [8]. Prompt surgical intervention using minimally invasive techniques could be advantageous in preventing such complications, thereby preserving organ function with minimal additional damage.
Tractotomy and segmentectomy were considered when the bullet track was observed in the basal segment of the left lower lobe [9] (Fig. 2B, C). Tractotomy may have necessitated extension of the surgical wound, while segmentectomy can result in a substantial reduction of pulmonary function. Since the patient was an athlete, preserving pulmonary function was prioritized, especially since only minimal bleeding was observed at the extraction site of the anterior basal segment. Additionally, the bleeding focus was managed through wedge resections and electric cauterization.
Soft tissue injuries resulting from gunshot wounds should be carefully examined and treated using standard wound care procedures. This includes the debridement of contaminated tissue, the administration of systemic antibiotics, and delayed primary sutures [2]. In military scenarios, adherence to these protocols is important due to likelihood of severe damage caused by high-velocity bullets, along with the presence of torn clothing fragments or other debris from the surrounding environment within the penetrating cavity. For civilian gunshot wounds, treatment can be better personalized to suit individual cases [2]. In the present case, the penetrating track on the anterior chest wall, caused by the extracted bullet, did not appear to be severely damaged or contaminated. After thorough debridement and irrigation, it was utilized for chest tube drainage.
Despite the patient’s initial hemodynamic stability and the lack of clear evidence of major mediastinal injuries, prompt surgical intervention was advantageous in preventing complications and preserving organ function. VATS techniques may offer a balance between aggressive open thoracotomy and the slow progress of conservative management. More aggressive and safe treatment strategies are needed, as younger patients are often at higher risk, even with injuries of the same severity as adults [10]. The benefits of VATS, such as rapid functional recovery, swift return to society, and preservation of organ function, have been well-documented.
Author contributions
Conceptualization: KL, EY. Data curation: YJ, KL, SH. Formal analysis: EY, KL. Methodology: SH, JHK, YJ, KL. Project administration: SL EY. Visualization: SH, JHK, KL, SL. Writing–original draft: SH, JHK EY. Writing–review & editing: SL EY.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
J Chest Surg 2024; 57(1): 87-91
Published online January 5, 2024 https://doi.org/10.5090/jcs.23.061
Copyright © Journal of Chest Surgery.
Seonyeong Heo , M.D., Jung Hee Kim
, M.D., Younggi Jung
, M.D., Ph.D., Kwanghyoung Lee
, M.D., Sungho Lee
, M.D., Ph.D., Eunjue Yi
, M.D., Ph.D.
Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
Correspondence to:Eunjue Yi
Tel 82-2-920-5436
Fax 82-2-920-5369
E-mail viking99@hanmail.net
ORCID
https://orcid.org/0000-0002-2403-6839
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gunshot-induced chest trauma is exceedingly rare among civilians in South Korea due to strong firearm control policies. In contrast to military reports emphasizing the use of emergent open thoracotomy to increase chances of survival, most penetrating non-cardiac injuries in civilian settings are managed conservatively, such as through chest tube insertion, as they typically result from lower-energy bullets. However, early surgical intervention for penetrating gunshot wounds can help reduce delayed fatalities caused by septic complications from pneumonia or empyema. The advent of minimally invasive thoracic surgery has provided cost-effective and relatively non-invasive treatment options, aided in the prevention of potential complications from undrained hematomas, and facilitated functional recovery and reintegration into society. We successfully treated a patient with a penetrating gunshot wound to the chest using video-assisted thoracoscopic surgery.
Keywords: Penetrating wounds, Video-assisted thoracic surgery, Case report
A 15-year-old male patient was admitted to the emergency room of Korea University Anam Hospital due to chest trauma. He was a shooting athlete who had accidentally been shot with a .22 caliber pistol during training. Upon arrival, his initial systolic blood pressure was 97 mm Hg, and his heart rate was 118 beats per minute. We observed a small wound (approximately 5 mm) on his left back, as well as a slightly larger wound in the upper left anterior chest wall. After securing the patient’s airway through intubation and initiating rapid transfusion via a central catheter inserted into the right jugular vein, we conducted an imaging study. An initial chest radiograph revealed a massive hemorrhage in the left thoracic cavity (Fig. 1A). A follow-up radiograph taken 30 minutes after arrival, along with chest computed tomography (CT) scans, showed an increasingly massive hematoma and a heart skewed to the right (Fig. 1B–D).
The patient was immediately taken to the operating room for exploration via video-assisted thoracoscopic surgery (VATS). General anesthesia was administered, and a double-lumen endotracheal intubation was performed. Upon thoracoscopic examination, a large quantity of fresh blood clots and bloody effusion was discovered. After the hematoma was evacuated, a wound of approximately 5 mm, potentially an entry wound, was identified at the 10th intercostal space (Fig. 2A). A penetrating track was also found, extending from the posterior to the anterior basal segment of the left lower lobe (Fig. 2B, C). The lingular segment of the left upper lobe exhibited a short bullet pathway (Fig. 2D, E), which was connected to a hole in the sixth intercostal space of the anterior chest wall (Fig. 2F). Due to continuous bleeding, the wound in the lingular segment and anterior basal segment were resected using a surgical stapler (Echelon Flex Powered 60 Endopath Stapler; Ethicon Inc., Somerville, NJ, USA). A tractotomy was not performed.
Following surgery, the patient was moved to the intensive care unit (ICU) while still under sedation and intubation. The day after surgery, extubation was performed, and the patient was moved to the general ward. Two chest tubes were inserted, along with 1 drain tube, which was inserted through the extraction wound on the anterior chest wall at the level of the fourth anterior intercostal space (Fig. 3A). The entry wound on the posterior chest wall was sutured (Fig. 3B). No hematoma was observed on the immediate postoperative chest radiograph (Fig. 3C) or in follow-up prior to discharge (Fig. 3D).
The chest tubes were removed 18 days after surgery due to a continuous air leak, and the patient was discharged on postoperative day 21. Follow-up chest CT scans were conducted 1 week and 1 month after surgery to monitor the resolution of any remaining hematoma and to detect potential complications. No permanent cavities caused by the trajectory or parenchymal damage were observed on a chest X-ray taken 33 months after the procedure. A subsequent chest CT scan was scheduled 2 years post-injury to identify any potential lingering complications.
This study was approved by the Institutional Review Board of Korea University Anam Hospital (IRB number: 2021AN0526). The patient and patient’s caregiver provided written informed consent for publication of the research details and clinical images.
Penetrating chest injuries caused by firearms frequently present complex challenges for healthcare providers, particularly if providers lack experience with such conditions. Previous studies have indicated that penetrating thoracic gunshot wounds in civilian settings can often be managed non-operatively, as they are typically associated with low-velocity bullets. This contrasts with injuries sustained in military incidents, which are usually caused by high-velocity missiles or shrapnel and often necessitate immediate open thoracotomy [1-3]. Immediate surgical intervention should be considered if the patient is in shock (systolic blood pressure <70 mm Hg), if the initial chest tube drainage exceeds 1,500 mL, if continuous hourly drainage surpasses 150 to 200 mL, or if injuries to mediastinal structures are suspected [1,4-6]. Non-cardiac penetrating chest trauma that does not present with symptoms of shock often does not require surgical intervention [1,3].
Upon initial physical examination, we identified an entry mark and wound on the patient’s chest wall. The patient’s blood pressure indicated that he was not in a state of shock. With rapid transfusion, his systolic blood pressure was maintained at over 70 mm Hg, and heart rate was kept under 120 beats per minute. Chest CT scans revealed no major injuries to the mediastinal structures. However, rather than opting for chest tube insertion and close observation through conservative management, we decided to proceed with immediate surgical intervention.
Several factors informed this decision. First, serial chest radiographs revealed increasing radiopacity in the left lung field (Fig. 1A, B), suggesting the possibility of ongoing bleeding. The chest CT scans displayed a substantial hematoma in the left thoracic cavity, with a rightward displacement of the heart (Fig. 1C, D). While chest tube insertion and ICU monitoring could alleviate the symptoms, there are only temporary solutions, particularly when specific injuries necessitate bleeding control.
The patient’s systolic blood pressure was maintained above 90 mm Hg through the rapid transfusion of five 400-mm packs of red blood cells and intravenous fluid resuscitation. Despite follow-up imaging studies revealing an increase in haziness in the left thoracic cavity, the mediastinal shift had not extensively deteriorated, leading us to suspect a decrease in bleeding rate. The entry and exit wound were of similar, size, suggesting that the bullet had not tumbled within the pulmonary parenchyma, and likely did not cause substantial damage. Upon examination of the chest CT, we found no signs of serious damage to major structures, including the pulmonary vessels, bronchus, and intercostal arteries.
The VATS procedure is considered a safe and affordable option that does not put patients at risk. In this case, it could also aid in achieving appropriate surgical management, including controlling the source of bleeding with minimal additional injury. Given that the patient was a promising 15-year-old athlete, preserving thoracic muscle strength and minimizing the surgical wound were considered beneficial, provided the patient’s condition remained stable. Isolated pulmonary gunshot trauma can substantially alter pulmonary function and respiratory muscle strength [7], so it was preferable to avoid potential additional damage caused by an open thoracotomy.
We posit that conservative management, which includes chest tube drainage, may be insufficient to eliminate a massive hemorrhage, even in the absence of ongoing bleeding injuries. Undrained hematomas can lead to delayed complications such as empyema, which may necessitate extensive surgical intervention, extended ICU care and hospitalization, delayed functional recovery, and, in rare cases, sepsis [8]. Prompt surgical intervention using minimally invasive techniques could be advantageous in preventing such complications, thereby preserving organ function with minimal additional damage.
Tractotomy and segmentectomy were considered when the bullet track was observed in the basal segment of the left lower lobe [9] (Fig. 2B, C). Tractotomy may have necessitated extension of the surgical wound, while segmentectomy can result in a substantial reduction of pulmonary function. Since the patient was an athlete, preserving pulmonary function was prioritized, especially since only minimal bleeding was observed at the extraction site of the anterior basal segment. Additionally, the bleeding focus was managed through wedge resections and electric cauterization.
Soft tissue injuries resulting from gunshot wounds should be carefully examined and treated using standard wound care procedures. This includes the debridement of contaminated tissue, the administration of systemic antibiotics, and delayed primary sutures [2]. In military scenarios, adherence to these protocols is important due to likelihood of severe damage caused by high-velocity bullets, along with the presence of torn clothing fragments or other debris from the surrounding environment within the penetrating cavity. For civilian gunshot wounds, treatment can be better personalized to suit individual cases [2]. In the present case, the penetrating track on the anterior chest wall, caused by the extracted bullet, did not appear to be severely damaged or contaminated. After thorough debridement and irrigation, it was utilized for chest tube drainage.
Despite the patient’s initial hemodynamic stability and the lack of clear evidence of major mediastinal injuries, prompt surgical intervention was advantageous in preventing complications and preserving organ function. VATS techniques may offer a balance between aggressive open thoracotomy and the slow progress of conservative management. More aggressive and safe treatment strategies are needed, as younger patients are often at higher risk, even with injuries of the same severity as adults [10]. The benefits of VATS, such as rapid functional recovery, swift return to society, and preservation of organ function, have been well-documented.
Author contributions
Conceptualization: KL, EY. Data curation: YJ, KL, SH. Formal analysis: EY, KL. Methodology: SH, JHK, YJ, KL. Project administration: SL EY. Visualization: SH, JHK, KL, SL. Writing–original draft: SH, JHK EY. Writing–review & editing: SL EY.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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