EMS calls a trauma alert for a gentleman injured from a shotgun blast about 20 minutes ago. By report he was shot from more than 6 feet away and sustained injuries to his L chest, back and abdomen. On arrival, he complains of chest/abdominal pain without respiratory distress or shock. He is awake & alert and has no injuries in the head & neck region. More than fifty shotgun pellet entry wounds are spread out along the L chest, back and L abdomen without major soft-tissue loss, consistent with a shotgun injury from a distance. Vitals are P 115, BP 155/72, RR 24, sat 95% RA. There is some subcutaneous air in the L chest region, and the patient has pain & guarding in the abdomen. There is no vascular deficit.

A screening trauma ultrasound shows no pericardial fluid and no free fluid in the abdomen. Chest X-ray and plain film of the abdomen are shown, with multiple pellets visible. You speak to the trauma surgeon on call who requests a CT scan to further define the extent of the injuries.      
As the patient rolls to CT, you review the plain films.  What do they show?  What actions do you anticipate?  
Conclusion on next page
{mospagebreak title=Conclusion} 
Dx: Birdshot Violating Chest and Abdomen

With this many pellets involved, AP and X-table views to determine violation of critical structures is nearly impossible. Here, CT shows its strength in identifying exactly where each pellet has gone. Clinically, this patient will likely require a L chest tube and a trip to the OR for his abdomen, as he almost certainly has a significant left pneumothorax & hemothorax, as well as violation of his peritoneum.

That was the easy part. We were concerned about a few of the pellets near the heart on the CXR (see circle). However, the most dangerous pellets were those near the base of the heart (arrows). It is easy to forget that the heart extends below the anterior dome of the diaphragm, so that the bottom of the heart is obscured by the upper abdomen on an AP CXR view. The two offending pellets (arrows), which are hard to see on the plain film, are actually in the pericardium (see CT scan).

This was a good lesson about the anatomic location of the heart in the chest, as well as its location relative to the normal contours on a CXR. This fellow got his chest tube, and went to surgery. After repairing more than 10 holes in his bowel, the surgeon performed a pericardial window and removed the cardiac pellets. There was no other injury to the heart. A lucky survivor.


John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course. www.emprepcourse.com

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