Gunshot wounds remain the most common cause of penetrating injuries in children and adolescents and the second leading cause of death among youth in the United States. Penetrating cardiac injuries carry a significantly increased mortality rate. The extent of damage caused depends on the type of firearm, the bullet used, the velocity and the trajectory. Therefore, rapid diagnosis and treatment is of the utmost importance.We report a case of a 19-year-old boy who presented to our emergency department (ED) after sustaining a gunshot wound (GSW) to the right chest. In the ED, the patient was stabilized and a large hematoma was evacuated during a resuscitative thoracotomy. Further thoracotomy in the operating room was done with repairs of the penetrating injuries to the heart and lungs. No bullet was identified after careful inspection of the entire chest in the operating room. However, upon further postoperative imaging, a bullet was identified on chest X-ray and CT, lodged in the anterior aspect of the subepicardial right ventricular outflow tract. After a complicated hospital course, the patient was discharged by hospital day 30 in a stable condition with outpatient follow-up.The decision to leave or retrieve a bullet should be made on a case-by-case basis depending on the clinical picture. In this case report, we have shown that leaving the bullet in place with close observation and appropriate imaging is feasible for selected patients.

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