A 21-year-old African American male reported to the trauma centre with a single gunshot wound to the posterior chest. The wound resulted in cervical tracheal injury and peripheral lung injury. The bullet was surgically removed and the patient was discharged 5 days post-injury
A 21-year-old African American male patient presented to the trauma centre with a single gunshot wound that penetrated the patient’s posterior, inferior and medial to the scapular spine. Emergency medical services performed a left needle thoracostomy for tension pneumothorax.
On examination, the patient was hemodynamically stable, moving all extremities and GCS 15. The patient was intubated and a chest tube with initial output of 700 ml was placed. A portable chest radiograph showed a bullet overlying the right inferior hilum. In addition, a secondary survey was performed which showed subcutaneous emphysema in the chest wall and neck. Given the stability of the patient, a computed tomography angiogram of the neck and chest was performed to asses the vessels and trajectory. However, there was no major vascular injury.
The bullet was located in the right inferior pulmonary hilum with no obvious landing of the bullet in the contralateral hemithorax. However, the large amount of pneumomediastinum suggested a large airway injury.
The patient was brought to the operating room for possible thoracic exploration, esophagoscopy and bronchoscopy
A bullet was seen lodged in the right bronchus intermedius on bronchoscopy with possible aspiration of the bullet from a left sided pulmonary wound or proximal airway injury. Bronchoscopic evaluation further identified a hole on the left anterolateral wall of the cervical trachea at the thoracic outlet. There was no marked injury of the esophagoscopy.
The bullet was retrieved using a bronchoscope with endoscopic forceps.
During the procedure, the patient required to be extubated and intubated. However, the diameter of the bullet was larger than the endotracheal tube. An incision was made along the anterior side of the sternocleidomastoid to explore the left side of the neck. An interrupted absorbable suture was used to repair the tracheal injury at the inferior aspect of the incision. Moreover, the suture was buttressed with a muscle flap from the sternocleidomastoid.
The patient was discharged five days post-injury and was on his road to recovery without any adverse complications.
Gunshot wounds to the posterior chest wall are a concern since it can ricochet into the cervical trachea and result in bullet aspiration into the right bronchus intermedius. This is the first published case of a thoracic gunshot wound that resulted in an isolated cervical tracheal injury. In addition, there was no peripheral injury noted noted on the radiograph.
References
Gun Shot Wound to Left Chest with “Transmediastinal” Trajectory. A Case Report and Review https://clinmedjournals.org/articles/tcr/trauma-cases-and-reviews-tcr-1-009.php?jid=tcr
