Unusual Case of Meandering Bullet in the Pericardial Cavity: Surgical Management and Clinical Considerations

Unusual Case of Meandering Bullet in the Pericardial Cavity: Surgical Management and Clinical Considerations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Unusual Case of Meandering Bullet in the Pericardial Cavity: Surgical Management and Clinical Considerations Ali Lotf Al-Amry, Abdu Shamsan, Raidan Al-Eryani, Yasser A-Moghni, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4298979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Foreign bodies of the pericardium are rare and are most commonly associated with significant trauma. With no associated injury in the myocardium, the finding of a meandering bullet alone in the pericardial cavity is rare. This is a case of an 18-year-old patient who came to the emergency room of 48 Model Hospital with a penetrating chest trauma associated with hemothorax and pneumothorax. The patient complained of dyspnea and chest pain during the presentation. Tube thoracostomy was performed on the day of admission. CT, fluoroscopy, and echocardiography show pericardial effusion and bullets are floating in the pericardial space. On the sixth day of admission, the patient underwent Lt thoracotomy and pericardiotomy with bullet removal. The patient was discharged on the 10th postoperative day. Despite reports supporting conservative management, surgical removal of the foreign body is recommended in cases of free bullets in the pericardial sac due to the high risk of developing clinical manifestations, pericarditis, and potential complications such as cardiac tamponade. The potential risks and damage caused by the foreign body should be carefully considered, outweighing the uncertain outcomes and complications associated with conservative treatment. Cardiothoracic Surgery Surgery Pericardial foreign bodies meandering bullet pericardial effusion surgical management conservative treatment Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction The reported incidence of foreign bodies in the pericardial sac after penetrating injury is rare, with available reports focusing mainly on bullets, shrapnel, circular saw fragments, and pendants. 1 – 4 These foreign bodies can be retained within the pericardial sac without causing a major cardiac injury. 5 The natural history of these foreign bodies and whether they require removal or observation is still debated. However, it is generally recommended to remove intrapericardial foreign bodies to prevent complications such as pericarditis. The diagnosis of intrapericardial foreign bodies can be challenging. Timely diagnosis and proper operative management are crucial for the successful treatment of penetrating cardiac injuries involving foreign bodies. In this case, we reported the removal of a meandering bullet from the pericardial sac in an 18-year-old woman. Case presentation An 18-year-old patient arrived in the Emergency Room (ER) of 48 Model Hospital within 10–15 minutes after sustaining a penetrating chest injury. Initially in good health, she suddenly experienced a hit to the upper border of her right scapula. The patient reported dyspnea and shoulder pain, which began abruptly after being hit by a ricochet bullet on the right side of her chest, posterior to the shoulder. Initially, she felt only slight pain, but it gradually increased along with the onset of dyspnea. Upon arrival in the ER, the patient was conscious, drowsy, and had a patent airway. However, the patient was dyspneic with a respiratory rate (RR) of 26 cycles / min, a pulse oximeter saturation of 89%, and an intact but weak peripheral pulse of 107 bpm. Inspecting the patient we found a small wound (inlet) measuring approximately 0.5 cm on the right upper border of the scapula, without active bleeding from the wound and without any corresponding outlet. By palpation, the trachea was shifted to the left side and by percussion there was stony dullness on the right side of the chest. By auscultation, there was absent air entry on the affected side. A chest radiograph revealed complete opacification of the Rt hemithorax with a shifting mediastinum to the left side and a metallic foreign body (bullet) lodged on the left side of the chest at the level of the fifth intercostal space, medial to the midclavicular line (Fig. 1 ). Immediately, a Rt side chest tube was inserted into the ER, with approximately 400 cc of blood initially drained. The patient was subsequently admitted to the Intensive Care Unit (ICU), where follow-up examinations indicated stable vital signs, including PR of 83 bpm, BP of 120/80 mmHg and oxygen saturation of 96%. A control chest radiograph was performed, revealing the chest tube in the correct position. However, it was observed that the bullet had moved to the level of the eighth intercostal space, laterally to the left midclavicular line (Fig. 2 ). By performing a computed tomography (CT) of the chest (Fig. 3 ), it revealed a massive right side hemothorax with mediastinal shift to the left side, along with mild pericardial effusion, and confirmed the presence of the bullet in the left hemithorax. Echocardiography revealed a mild pericardial effusion, but the patient's clinical condition remained stable. On the fourth day of hospital admission, a follow-up chest CT scan showed an increased amount of pericardial effusion and a moderate amount of pleural effusion on the left side (Fig. 4 ). Subsequently, left side chest tube was inserted, with approximately 500 ml of serous fluid initially drained. A fluoroscopy with gastrographin swallow revealed normal passage of contrast and also confirmed that the bullet was freely mobile within the pericardial space (Fig. 5 ). Based on the findings and after multidisciplinary team discussion, the decision was made to proceed with surgery to remove the bullet and prevent cardiac tamponade. Therefore, on the sixth day of admission, the patient underwent a left thoracotomy and pericardiotomy under general anesthesia with double-lumen endotracheal intubation (Fig. 6 ). The patient was placed in the right lateral position and prepared for the thoracotomy. A thorough assessment of the left hemithorax was performed and 200 ml of serous fluid was drained. During inspection, an enlarged heart was observed, indicating a retained hemopericardium. A 4 cm longitudinal incision was made in the pericardial sac after identifying the phrenic nerve. Subsequently, approximately 300 ml of serosanguineous fluid was evacuated from the pericardial cavity and the bullet was extracted (Fig. 7 ), resulting in immediate improvement in cardiac contraction. Upon complete inspection of the left hemithorax, the chest tube was left in place for continuous drainage. The patient tolerated the procedure well and was extubated on the first postoperative day, with progressively decreasing chest tube drainage. On the fifth postoperative day, the patient was transferred from the ICU to the surgical ward. On the sixth day postoperative, the bilateral chest tubes were removed. The patient was finally discharged on the tenth postoperative day without any major complaints with a follow-up chest radiograph confirmed the absence of any recurrent effusions (Fig. 8 ). Discussion In the case presented, an 18-year-old female patient was admitted to the ER shortly after sustaining a gunshot wound, resulting in a retained bullet in the pericardial sac. The patient exhibited symptoms of dyspnea and shoulder pain, with clinical findings of tracheal deviation, decreased air entry on the right side, and a small entry wound without an exit. Initial imaging and interventions included a chest radiograph, which revealed a bullet lodged near the heart, and a chest tube insertion that drained a significant amount of blood. During the course of her hospital stay, follow-up examinations and imaging showed an increase in pericardial effusion, prompting a decision to surgically remove the bullet to prevent potential complications such as cardiac tamponade. The patient underwent a successful left thoracotomy and pericardiotomy, with postoperative recovery in the ICU and subsequent transfer to the ward without incident. The occurrence of penetrating cardiac injuries with bullets retained in the pericardial sac is relatively rare, and the management of such cases, especially when the patient is asymptomatic, can be controversial. 4 Discussing the management strategies in these cases is vital, as it helps to highlight the variability in clinical presentations and the need for individualized treatment approaches. It also underscores the importance of a multidisciplinary team in making timely and appropriate decisions regarding conservative treatment versus surgical intervention, considering the potential risks and benefits for the patient. The discussion of such cases adds valuable insights to the medical literature, guiding clinicians in the management of similar future cases and contributing to the development of best-practice guidelines. The management strategy in the case presented, which involved surgical removal of the bullet due to increased pericardial effusion, aligns with established practices for cases where the risk of complications justifies surgical intervention. However, it is also evident from the literature that conservative management may be considered for asymptomatic patients or in cases where the surgical risks outweigh the benefits. The decision must be individualized and based on a thorough assessment of the patient's condition and the potential for complications. A case report by Kaya et al. (2016) detailed the management of a penetrating gunshot injury to the heart where a bullet was retained in the pericardial sac. The patient presented pericardial effusion and management included surgical retrieval of the bullet. 6 This is consistent with the surgical intervention applied in the presented case, where the bullet was also surgically removed after the development of pericardial effusion. On the other hand, a literature review by Lundy et al. (2009) on the conservative management of retained cardiac missiles (RCMs) suggests that not all cases require surgical removal. The study placed RCM within the pericardial sac into a category where the risk of complications and ease of retrieval could make a case for conservative management unless there are changes in the patient's condition or the RCM itself. 7 Another study in Brazil discusses the management of bullets lodged in the heart, highlighting that bullets can be embedded in the myocardium or found free inside the heart chambers or pericardial sac. The management approach depends on the location of the bullet and the clinical stability of the patient. 8 Compared to the management of heart stab wounds and bullets, a historical perspective by GERAMI et al. (1968) discusses the importance of immediate surgical treatment in cases with significant clots in the pericardial sac, a situation that could require prompt surgical intervention. 9 In the case presented, various diagnostic methods were used to assess the extent of the injury and the position of the retained bullet. Initially, a chest radiograph was used, which is a common and effective method to identify penetrating cardiac injuries and associated hemothorax or pneumothorax. However, the ability of chest radiograph to provide detailed information is limited and, as such, further imaging with a CT scan was conducted. The CT scan revealed a large right-sided hemothorax with mediastinal shift and confirmed the presence of the bullet in the left hemithorax, highlighting its effectiveness in identifying the bullet and associated injuries in cases of penetrating cardiac injury. 10 The treatment approach in this case began with conservative management, including insertion of the chest tube and close monitoring. As the patient's condition evolved, with increased pericardial effusion observed on follow-up CT scans, the decision was made to proceed with surgery. This decision aligns with other reports in which surgical intervention is recommended in the presence of complications such as increased pericardial effusion or the risk of cardiac tamponade. 11 Surgical removal of retained bullets in the pericardial sac is a recommended approach, particularly when the retained missile poses a risk of complications. A review of the literature on conservative management of retained cardiac missiles suggests that while some asymptomatic patients can be conservatively managed, those with symptoms or complications should undergo surgery. 7 Compared to the guidelines for the treatment of penetrating cardiac injury with retained bullet, the management of this case demonstrates adherence to recommended practices, which suggest the removal of the bullet in the presence of clinical or imaging evidence of potential complications. 12 The use of a multimodal imaging approach, including chest radiographs and CT scans, followed by surgical intervention when necessary, is consistent with the recommended strategies for such injuries. 13 The case contributes to the literature by strengthening the importance of individualized treatment plans based on the evolving clinical picture of the patient and the diagnostic information provided by imaging techniques. The management approach taken in the presented case has several strengths. The timely intervention was a key strength, as early recognition and rapid response to the injury can significantly improve outcomes in cases of penetrating cardiac injuries. Accurate diagnosis through the use of chest radiographs and CT scans allowed precise localization of the bullet and assessment of associated injuries, informing the decision-making process for the best course of treatment. Effective surgical techniques, including thoracotomy and pericardiotomy, were used to successfully remove the bullet, which mitigated the risk of further complications such as cardiac tamponade or arrhythmias. These strengths contributed to a successful outcome for the patient, allowing for rapid and complete recovery without the development of further complications. 14 , 15 Potential weaknesses or limitations in the approach may include the risks associated with surgery, such as infection or damage to cardiac structures. Alternative strategies, such as nonoperative management, could have been considered if the patient remained asymptomatic and stable. However, in this case, the increase in pericardial effusion indicated the need for surgical intervention. Any delays in treatment could have led to a worsening of the patient's condition, but we promptly acted on the changes observed in the patient's condition. Challenges in management may include making the decision between conservative and surgical treatment, assessing the risks of bullet migration or embolism, and ensuring the hemodynamic stability of the patient throughout the process. We overcome these challenges through thorough monitoring, multidisciplinary collaboration, and adherence to established guidelines for penetrating cardiac injuries with retained missiles. 11 , 12 Conclusions Despite reports supporting conservative management, surgical removal of the foreign body is recommended in cases of free bullets in the pericardial sac due to the high risk of developing clinical manifestations, pericarditis, and potential complications such as cardiac tamponade. The potential risks and damage caused by the foreign body should be carefully considered, outweighing the uncertain outcomes and complications associated with conservative treatment. Abbreviations ER Emergency Room ICU Intensive Care Unit CT Computed Tomography scan RCMs Retained cardiac missiles. Declarations Acknowledgments We thank the patient for providing consent for this study. Ethics approval and consent to participate This case report was approved by the Ethics Committee of the 48 Model Hospital. Consent for publication Informed consent was obtained from the patient for the publication of this case report. Potential patient identifications were excluded from the report. Disclosure The authors declare that they have no conflict of interest. Funding The authors received no funding for this study. Materials and Data Availability Data regarding this case report are available with the corresponding author on reasonable request. References Fike F, Juang D, Muensterer O, O’Brien J Jr, Ostlie D, St Peter S (2011) Intrapericardial Foreign Bodies in the Pediatric Trauma Population. Eur J Pediatr Surg 21(06):410–412. 10.1055/s-0031-1283153 Nougarolis F, Mokrane FZ, Brouchet L et al (2017) An unusual intracardiac foreign body following penetrating thoracic injury. Diagn Interv Imaging 98(12):901–902. 10.1016/j.diii.2017.10.001 Benedetto U, Caputo M, Kosti A et al (2019) Cupid’s arrow retained in the heart. J Thorac Dis 11(1):E1–E3. 10.21037/jtd.2018.12.12 Marsico GA, de Almeida AL, de Azevedo DE, Mathias Filho I (2009) Projétil intrapericárdico móvel. Revista Brasileira de Cirurgia Cardiovasc 24(1):84–87. 10.1590/S0102-76382009000100016 Abdelwahab Alassal M (2022) Unusual Penetrating, Retained Cardiac Intramural Foreign Body: Case Report. Med J Clin Trials Case Stud 6(1). 10.23880/MJCCS-16000308 Kaya A, Caliskan E, Tatlisu MA et al (2016) A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart. Case Rep Cardiol 2016:1–4. 10.1155/2016/2427681 Lundy JB, Johnson EK, Seery JM, Pham T, Frizzi JD, Chasen AB (2009) Conservative Management of Retained Cardiac Missiles: Case Report and Literature Review. J Surg Educ 66(4):228–235. 10.1016/j.jsurg.2009.04.002 Meira EB, de Guidugli S, Meira RB, de Rocha DB, Ghefter RM, Richter MC (2005) Abordagem terapêutica dos projéteis retidos no coração. Revista Brasileira de Cirurgia Cardiovasc 20(1):91–93. 10.1590/S0102-76382005000100020 GERAMI S, COUSAR JE, MOSELEY TM, MANAGEMENT OF STAB, AND BULLET WOUNDS OF THE HEART (1968). J Trauma Acute Care Surg. ;8(2) Selvakumar S, Newsome K, Nguyen T, McKenny M, Bilski T, Elkbuli A (2022) The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm? J Surg Res 276:120–135. 10.1016/j.jss.2022.02.018 Ball CG, Lee A, Kaminsky M, Hameed SM (2022) Technical considerations in the management of penetrating cardiac injury. Can J Surg 65(5):E580–E592. 10.1503/cjs.008521 Bolaji T, Ekpendu AC, Giberson F (2022) Gunshot Wound to the Chest With Retained Epicardial Bullet. Cureus Published online September 21. 10.7759/cureus.29422 Illman JE, Maleszewski JJ, Byrne SC et al (2016) Multimodality imaging of foreign bodies in and around the heart. Future Cardiol 12(3):351–371. 10.2217/fca-2015-0010 Mayrose J, Jehle DV, Moscati R, Lerner EB, Abrams BJ (1999) Comparison of Staples versus Sutures in the Repair of Penetrating Cardiac Wounds. J Trauma Acute Care Surg. ;46(3) Beall AC, Diethrich EB, Crawford HW, Cooley DA, De Bakey ME (1966) Surgical management of penetrating cardiac injuries. Am J Surg 112(5):686–692. 10.1016/0002-9610(66)90105-X Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4298979","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":293583504,"identity":"6a217a11-0846-4d72-8cbf-61a3f347258c","order_by":0,"name":"Ali Lotf 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arrow).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/dbae6bf935b20915ae367e8b.png"},{"id":55340026,"identity":"31b45a37-9d4d-4bdf-bb83-227b8d8d9ee1","added_by":"auto","created_at":"2024-04-26 01:59:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":260864,"visible":true,"origin":"","legend":"\u003cp\u003eA control chest radiograph shows the left side chest tube in the correct position, and the bullet moved to the level of the eighth intercostal space, laterally to the left midclavicular line.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/d078c59b246015f562bec06a.png"},{"id":55340029,"identity":"5813fdd3-3308-4d64-92f4-f7be78a622c0","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":306216,"visible":true,"origin":"","legend":"\u003cp\u003eA CT scan of the thorax axial view (A), coronal view (B), showing bilateral pleural effusions (white arrows), and mild fluid around the pericardium (red arrow).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/daace6675d009eab2e726303.png"},{"id":55340030,"identity":"900e7ff6-dc47-4ffc-972e-f7a50e423641","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":297982,"visible":true,"origin":"","legend":"\u003cp\u003eA follow-up chest CT scan \u0026nbsp;(axial view) shows an increased amount of pericardial effusion and a moderate amount of pleural effusion on the left side.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/bbaf689b087a33ba8926c322.png"},{"id":55340034,"identity":"f77013ce-6087-41c8-8dd0-c86acedf4fa4","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":565244,"visible":true,"origin":"","legend":"\u003cp\u003eFluoroscopy with contrast shows normal passage of contrast in the esophagus and shows the bullet floating in the pericardium.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/973bf724bf8b59879e88f9bd.png"},{"id":55340031,"identity":"8419f206-b7d6-44d5-8c31-37d03800e69a","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":344979,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image of left pleural cavity and left lung during thoracotomy (black arrow).\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/2022c789976714e56f0ed4f5.png"},{"id":55340032,"identity":"dfbebd09-6112-4a14-9039-dc0bea4fcb50","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":257180,"visible":true,"origin":"","legend":"\u003cp\u003eA Photograph of the removed bullet from pericardial space.\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/c3aa3b948264ddda6f770e71.png"},{"id":55340033,"identity":"474c26ca-cc84-4fc4-97ba-d8c952a1f962","added_by":"auto","created_at":"2024-04-26 01:59:34","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":251009,"visible":true,"origin":"","legend":"\u003cp\u003eA follow-up chest radiograph \u0026nbsp;on the tenth postoperative day shows no recurrent pleural effusions.\u003c/p\u003e","description":"","filename":"Figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/a19f8a8a3a5984beba189712.png"},{"id":55341514,"identity":"3e0bbdd4-f504-4702-9385-1f174359d061","added_by":"auto","created_at":"2024-04-26 02:15:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4977198,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4298979/v1/f09708ca-1177-49a6-ae25-3ef61eb254f8.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eUnusual Case of Meandering Bullet in the Pericardial Cavity: Surgical Management and Clinical Considerations\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe reported incidence of foreign bodies in the pericardial sac after penetrating injury is rare, with available reports focusing mainly on bullets, shrapnel, circular saw fragments, and pendants.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e These foreign bodies can be retained within the pericardial sac without causing a major cardiac injury.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The natural history of these foreign bodies and whether they require removal or observation is still debated. However, it is generally recommended to remove intrapericardial foreign bodies to prevent complications such as pericarditis. The diagnosis of intrapericardial foreign bodies can be challenging. Timely diagnosis and proper operative management are crucial for the successful treatment of penetrating cardiac injuries involving foreign bodies. In this case, we reported the removal of a meandering bullet from the pericardial sac in an 18-year-old woman.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eAn 18-year-old patient arrived in the Emergency Room (ER) of 48 Model Hospital within 10\u0026ndash;15 minutes after sustaining a penetrating chest injury. Initially in good health, she suddenly experienced a hit to the upper border of her right scapula. The patient reported dyspnea and shoulder pain, which began abruptly after being hit by a ricochet bullet on the right side of her chest, posterior to the shoulder. Initially, she felt only slight pain, but it gradually increased along with the onset of dyspnea.\u003c/p\u003e \u003cp\u003eUpon arrival in the ER, the patient was conscious, drowsy, and had a patent airway. However, the patient was dyspneic with a respiratory rate (RR) of 26 cycles / min, a pulse oximeter saturation of 89%, and an intact but weak peripheral pulse of 107 bpm. Inspecting the patient we found a small wound (inlet) measuring approximately 0.5 cm on the right upper border of the scapula, without active bleeding from the wound and without any corresponding outlet. By palpation, the trachea was shifted to the left side and by percussion there was stony dullness on the right side of the chest. By auscultation, there was absent air entry on the affected side.\u003c/p\u003e \u003cp\u003eA chest radiograph revealed complete opacification of the Rt hemithorax with a shifting mediastinum to the left side and a metallic foreign body (bullet) lodged on the left side of the chest at the level of the fifth intercostal space, medial to the midclavicular line (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Immediately, a Rt side chest tube was inserted into the ER, with approximately 400 cc of blood initially drained. The patient was subsequently admitted to the Intensive Care Unit (ICU), where follow-up examinations indicated stable vital signs, including PR of 83 bpm, BP of 120/80 mmHg and oxygen saturation of 96%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA control chest radiograph was performed, revealing the chest tube in the correct position. However, it was observed that the bullet had moved to the level of the eighth intercostal space, laterally to the left midclavicular line (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). By performing a computed tomography (CT) of the chest (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), it revealed a massive right side hemothorax with mediastinal shift to the left side, along with mild pericardial effusion, and confirmed the presence of the bullet in the left hemithorax. Echocardiography revealed a mild pericardial effusion, but the patient's clinical condition remained stable.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn the fourth day of hospital admission, a follow-up chest CT scan showed an increased amount of pericardial effusion and a moderate amount of pleural effusion on the left side (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Subsequently, left side chest tube was inserted, with approximately 500 ml of serous fluid initially drained. A fluoroscopy with gastrographin swallow revealed normal passage of contrast and also confirmed that the bullet was freely mobile within the pericardial space (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the findings and after multidisciplinary team discussion, the decision was made to proceed with surgery to remove the bullet and prevent cardiac tamponade. Therefore, on the sixth day of admission, the patient underwent a left thoracotomy and pericardiotomy under general anesthesia with double-lumen endotracheal intubation (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The patient was placed in the right lateral position and prepared for the thoracotomy. A thorough assessment of the left hemithorax was performed and 200 ml of serous fluid was drained. During inspection, an enlarged heart was observed, indicating a retained hemopericardium. A 4 cm longitudinal incision was made in the pericardial sac after identifying the phrenic nerve. Subsequently, approximately 300 ml of serosanguineous fluid was evacuated from the pericardial cavity and the bullet was extracted (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), resulting in immediate improvement in cardiac contraction. Upon complete inspection of the left hemithorax, the chest tube was left in place for continuous drainage.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient tolerated the procedure well and was extubated on the first postoperative day, with progressively decreasing chest tube drainage. On the fifth postoperative day, the patient was transferred from the ICU to the surgical ward. On the sixth day postoperative, the bilateral chest tubes were removed. The patient was finally discharged on the tenth postoperative day without any major complaints with a follow-up chest radiograph confirmed the absence of any recurrent effusions (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the case presented, an 18-year-old female patient was admitted to the ER shortly after sustaining a gunshot wound, resulting in a retained bullet in the pericardial sac. The patient exhibited symptoms of dyspnea and shoulder pain, with clinical findings of tracheal deviation, decreased air entry on the right side, and a small entry wound without an exit. Initial imaging and interventions included a chest radiograph, which revealed a bullet lodged near the heart, and a chest tube insertion that drained a significant amount of blood. During the course of her hospital stay, follow-up examinations and imaging showed an increase in pericardial effusion, prompting a decision to surgically remove the bullet to prevent potential complications such as cardiac tamponade. The patient underwent a successful left thoracotomy and pericardiotomy, with postoperative recovery in the ICU and subsequent transfer to the ward without incident.\u003c/p\u003e \u003cp\u003eThe occurrence of penetrating cardiac injuries with bullets retained in the pericardial sac is relatively rare, and the management of such cases, especially when the patient is asymptomatic, can be controversial.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Discussing the management strategies in these cases is vital, as it helps to highlight the variability in clinical presentations and the need for individualized treatment approaches. It also underscores the importance of a multidisciplinary team in making timely and appropriate decisions regarding conservative treatment versus surgical intervention, considering the potential risks and benefits for the patient. The discussion of such cases adds valuable insights to the medical literature, guiding clinicians in the management of similar future cases and contributing to the development of best-practice guidelines.\u003c/p\u003e \u003cp\u003eThe management strategy in the case presented, which involved surgical removal of the bullet due to increased pericardial effusion, aligns with established practices for cases where the risk of complications justifies surgical intervention. However, it is also evident from the literature that conservative management may be considered for asymptomatic patients or in cases where the surgical risks outweigh the benefits. The decision must be individualized and based on a thorough assessment of the patient's condition and the potential for complications.\u003c/p\u003e \u003cp\u003eA case report by Kaya et al. (2016) detailed the management of a penetrating gunshot injury to the heart where a bullet was retained in the pericardial sac. The patient presented pericardial effusion and management included surgical retrieval of the bullet.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This is consistent with the surgical intervention applied in the presented case, where the bullet was also surgically removed after the development of pericardial effusion.\u003c/p\u003e \u003cp\u003eOn the other hand, a literature review by Lundy et al. (2009) on the conservative management of retained cardiac missiles (RCMs) suggests that not all cases require surgical removal. The study placed RCM within the pericardial sac into a category where the risk of complications and ease of retrieval could make a case for conservative management unless there are changes in the patient's condition or the RCM itself.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAnother study in Brazil discusses the management of bullets lodged in the heart, highlighting that bullets can be embedded in the myocardium or found free inside the heart chambers or pericardial sac. The management approach depends on the location of the bullet and the clinical stability of the patient.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCompared to the management of heart stab wounds and bullets, a historical perspective by GERAMI et al. (1968) discusses the importance of immediate surgical treatment in cases with significant clots in the pericardial sac, a situation that could require prompt surgical intervention.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the case presented, various diagnostic methods were used to assess the extent of the injury and the position of the retained bullet. Initially, a chest radiograph was used, which is a common and effective method to identify penetrating cardiac injuries and associated hemothorax or pneumothorax. However, the ability of chest radiograph to provide detailed information is limited and, as such, further imaging with a CT scan was conducted. The CT scan revealed a large right-sided hemothorax with mediastinal shift and confirmed the presence of the bullet in the left hemithorax, highlighting its effectiveness in identifying the bullet and associated injuries in cases of penetrating cardiac injury.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe treatment approach in this case began with conservative management, including insertion of the chest tube and close monitoring. As the patient's condition evolved, with increased pericardial effusion observed on follow-up CT scans, the decision was made to proceed with surgery. This decision aligns with other reports in which surgical intervention is recommended in the presence of complications such as increased pericardial effusion or the risk of cardiac tamponade.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSurgical removal of retained bullets in the pericardial sac is a recommended approach, particularly when the retained missile poses a risk of complications. A review of the literature on conservative management of retained cardiac missiles suggests that while some asymptomatic patients can be conservatively managed, those with symptoms or complications should undergo surgery.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCompared to the guidelines for the treatment of penetrating cardiac injury with retained bullet, the management of this case demonstrates adherence to recommended practices, which suggest the removal of the bullet in the presence of clinical or imaging evidence of potential complications.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The use of a multimodal imaging approach, including chest radiographs and CT scans, followed by surgical intervention when necessary, is consistent with the recommended strategies for such injuries.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The case contributes to the literature by strengthening the importance of individualized treatment plans based on the evolving clinical picture of the patient and the diagnostic information provided by imaging techniques.\u003c/p\u003e \u003cp\u003eThe management approach taken in the presented case has several strengths. The timely intervention was a key strength, as early recognition and rapid response to the injury can significantly improve outcomes in cases of penetrating cardiac injuries. Accurate diagnosis through the use of chest radiographs and CT scans allowed precise localization of the bullet and assessment of associated injuries, informing the decision-making process for the best course of treatment. Effective surgical techniques, including thoracotomy and pericardiotomy, were used to successfully remove the bullet, which mitigated the risk of further complications such as cardiac tamponade or arrhythmias. These strengths contributed to a successful outcome for the patient, allowing for rapid and complete recovery without the development of further complications.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePotential weaknesses or limitations in the approach may include the risks associated with surgery, such as infection or damage to cardiac structures. Alternative strategies, such as nonoperative management, could have been considered if the patient remained asymptomatic and stable. However, in this case, the increase in pericardial effusion indicated the need for surgical intervention. Any delays in treatment could have led to a worsening of the patient's condition, but we promptly acted on the changes observed in the patient's condition. Challenges in management may include making the decision between conservative and surgical treatment, assessing the risks of bullet migration or embolism, and ensuring the hemodynamic stability of the patient throughout the process. We overcome these challenges through thorough monitoring, multidisciplinary collaboration, and adherence to established guidelines for penetrating cardiac injuries with retained missiles.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite reports supporting conservative management, surgical removal of the foreign body is recommended in cases of free bullets in the pericardial sac due to the high risk of developing clinical manifestations, pericarditis, and potential complications such as cardiac tamponade. The potential risks and damage caused by the foreign body should be carefully considered, outweighing the uncertain outcomes and complications associated with conservative treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Room\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography scan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCMs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRetained cardiac missiles.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient for providing consent for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was approved by the Ethics Committee of the 48 Model Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for the publication of this case report. Potential patient identifications were excluded from the report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Data Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData regarding this case report are available with the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFike F, Juang D, Muensterer O, O\u0026rsquo;Brien J Jr, Ostlie D, St Peter S (2011) Intrapericardial Foreign Bodies in the Pediatric Trauma Population. 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Cureus Published online September 21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.29422\u003c/span\u003e\u003cspan address=\"10.7759/cureus.29422\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIllman JE, Maleszewski JJ, Byrne SC et al (2016) Multimodality imaging of foreign bodies in and around the heart. Future Cardiol 12(3):351\u0026ndash;371. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2217/fca-2015-0010\u003c/span\u003e\u003cspan address=\"10.2217/fca-2015-0010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayrose J, Jehle DV, Moscati R, Lerner EB, Abrams BJ (1999) Comparison of Staples versus Sutures in the Repair of Penetrating Cardiac Wounds. J Trauma Acute Care Surg. ;46(3)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeall AC, Diethrich EB, Crawford HW, Cooley DA, De Bakey ME (1966) Surgical management of penetrating cardiac injuries. Am J Surg 112(5):686\u0026ndash;692. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/0002-9610(66)90105-X\u003c/span\u003e\u003cspan address=\"10.1016/0002-9610(66)90105-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sana'a University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pericardial foreign bodies, meandering bullet, pericardial effusion, surgical management, conservative treatment","lastPublishedDoi":"10.21203/rs.3.rs-4298979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4298979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eForeign bodies of the pericardium are rare and are most commonly associated with significant trauma. With no associated injury in the myocardium, the finding of a meandering bullet alone in the pericardial cavity is rare. This is a case of an 18-year-old patient who came to the emergency room of 48 Model Hospital with a penetrating chest trauma associated with hemothorax and pneumothorax. The patient complained of dyspnea and chest pain during the presentation. Tube thoracostomy was performed on the day of admission. CT, fluoroscopy, and echocardiography show pericardial effusion and bullets are floating in the pericardial space. On the sixth day of admission, the patient underwent Lt thoracotomy and pericardiotomy with bullet removal. The patient was discharged on the 10th postoperative day. Despite reports supporting conservative management, surgical removal of the foreign body is recommended in cases of free bullets in the pericardial sac due to the high risk of developing clinical manifestations, pericarditis, and potential complications such as cardiac tamponade. The potential risks and damage caused by the foreign body should be carefully considered, outweighing the uncertain outcomes and complications associated with conservative treatment.\u003c/p\u003e","manuscriptTitle":"Unusual Case of Meandering Bullet in the Pericardial Cavity: Surgical Management and Clinical Considerations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-26 01:59:29","doi":"10.21203/rs.3.rs-4298979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"April 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30941793,"name":"Cardiothoracic Surgery"},{"id":30941794,"name":"Surgery"}],"tags":[],"updatedAt":"2024-04-26T01:59:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-26 01:59:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4298979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4298979","identity":"rs-4298979","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}