Cardiac Gunshot Injury: Child with Stable Presentation and Asymptomatic Short‐Term Follow‐up

Abstract

A 2-year-old female child was brought to the emergency department after she was accidentally shot by her father, while cleaning his air rifle loaded with the pointed type 0.22 (5.5 mm) caliber pellet. The pellet hit the front of chest from a distance of about 10-15 m. On physical examination, it was found that there was entrance wound in right lower parasternal area but no exit wound. She was hemodynamically stable with normal auscultatory findings. Chest roentgenogram (Fig. 1) demonstrated a bullet overlying cardiac silhouette with no other findings. Two-dimensional transthoracic echocardiography (Figs, 2, 3, and movie clip 1) showed an echogenic density in the interventricular septum just beneath the insertion of tricuspid and mitral leaflets. The atrioventricular valves appear normal with no regurgitation. The biventricular function also appeared normal with no regional wall motion abnormalities. There was no pericardial effusion present. The echogenicity is most likely the pellet that punctured the chest wall and continued inward to lodge in the interventricular septum. Computed tomographic scan of the chest showed an intracardiac foreign body without other abnormalities. Up to 11 months, repeated scans have shown no changes. She will continue to receive ongoing follow-up to assess for late complications (migration, erosion, conduction, disturbance, etc.) To the best of our knowledge, she may be the youngest living patient having cardiac trauma with clinically stable presentation and asymptomatic short-term follow-up.

Air Gun Ballistic Projectile Lodged in the Interventricular Septum of an Asymptomatic Dog

“…In a case report of a 2-year-old child shot with a similar projectile fired from an air rifle, the projectile was also reported to be lodged within the interventricular septum. 11 Because air guns do not use explosives to expel projectiles, in the United States, they are not classified by the Bureau of Alcohol, Tobacco, Firearms, and Explosives as firearms. 12 Ownership laws and restrictions regulating nonpowder guns vary from state to state.…”

“…14 Nevertheless, whether air guns are subsonic, high velocity, or designated as firearms or not, their missiles are capable of penetrating vital organs and can result in substantial morbidity, as well as life-threatening and fatal injuries. 11,[15][16][17] In the case presented here, we presumed that a direct, penetrating gunshot wound to the heart was plausible to explain the projectile's being completely embedded within the approximately 9-mm-thick basal interventricular septum. As such, the ballistic projectile would have had to contain sufficient velocity and energy, relative to the distance between the patient and weapon, to perforate skin, muscle, lung, pericardium, and heart.…”

“…Such findings also were reported in a young child who sustained a penetrating cardiac injury from a similar ballistic projectile that was fired from an air gun. 11 However, we could not exclude the alternative possibility that the heart was the final destination for the ballistic projectile, following a wound to the systemic venous system that embolized to the right heart. Although rare, bullet embolization is a potential complication of penetrating gunshot wounds when metallic ballistic projectiles gain access to the vascular compartment, and projectiles embedded within the myocardium have been reported.…”