I have had patients who have arrested with pericardial tamponade and only obtained less than 10 mls of pericardial fluid/blood from pericardiocentsis.  My guess would be tamponade given the presentation as well as the location (subcaribal) of the projectile.  Hopefully autopsy will fill-in the rest of the gaps.  Thanks for the good case presentation, but I am so sorry for the loss of life in this case!!

Thanks a lot

I Agree with thoracoscopy but aiming for what?

Thanks a lot. 

What do u think was the cause of death?

THESE ARE VERY INTERSTING GUIDELINES, A friend just told me about them. I will recommend every body to read them.

Sorry do you mean subcarinal? 

Could this patient have had embolism and the culprit being cerebral rather than cardiopulmonary? The fact of good blood gases and no tamponade suggests this.

it would be interesting what the autopsy would reveal.

Stanley, brilliant suggestion:

Sameh what were the autopsy results?

Postmortem? Many possibilities, cardiac contusion delayed rupture, coronary contusion/laceration delayed thrombosis or rupture, vascular injury partial thickness with delayed rupture. air embolus cardiac, cerebral, coronary; thrombus embolus coronary, pulmonary, cerebral; bullet embolus, cerebral, cardiac. myocardial infarction, with or without delayed rupture; drop in hematocrit, electrolyte abnormality, comorbid medical problem, malfunctioning equipment, nefarious activity (e.g. the person who shot him came back to finish it off?), and a good many many other reasons. Something was missed, when things don't look right, do as ATLS taught us, go back from the beginning and do complete surveys, primary, secondary, tertiary to pick up what was missed. So, what were the results?

Dear Dr. Sersar,

= We need more clinical information.

= Clinically: Where in the right intercostal space was the penetration? Parasternal, mid clavícular, or anterior axillary line? Rt. 3rd or 4rth intercostal rib fragmented, intercostal vascular bundle intact? This determines the trajectory of the bullet.

= On Xray- was the shape of bullet, fragmented or intact, position below the sub-CARINA, midline or-on left or right of mainstem bronchi. This will tell you that: 1. If bullet was spent 2. shape of bullet - intact. 3. Was it Fragmented causing collateral widespread injury 3. pathway of bullet. Etc...= WHY is it that if the bullet had regular velocity it did not penetrate through more VERY soft tissue? Was it’s spent low velocity bullet or a bullet in its terminal flight ? Fragmented soft nosed mushrooming bullet produces more impact injury and your bullet seemed to have a downward angle to sit below the carina.

= Pathway trajectory seemed to be slightly downward and medially- traversing soft tissue of muscle, lung parenchyma, and perhaps “nicking” some blood vessels, to wit: intercostal right anteriorly and posteriorly, scattered fragments involving the Azygos V., ( Hemothorax)

= The Carina moves up and down from about the level of the 5th to the 7th vertebral body, so this patient must have been in inspiration for the bullet to be located below it AND related to the point of entry should tell you that it traversed Downward through ONLY soft tissue.

= You said there was no tamponade but you must have suspected also a pericardial injury because you tapped to drain some blood! Blood should have been Absent in the pericardial sac!!!

= No cardiac damage with good SpO2 !!

= A pity he died!

= The absence of technological finding does NOT eliminate the suspicion hence the impression that he had a Tamponade.

= When I was a surgical resident in training, I had a patient who was stabbed thru the mid sternal bone. He was admitted for observation although he was not symptomatic. Later he developed symptoms mimicking you case. After a positive pericardial tap, he was explored and the knife only penetrated to the root of the ascending aorta and nicking a small rent in the pericardium which was the entry of the blood to cause the bloody pericardial effusion. All he needed was a couple of stitches to the aorta and a pericardial drainage. He went home happy.

= Anatomical exam should clear up our hypotheses. A challenging case!

= Once, I was called to assist on a case shot with a .45 Cal on his right flank at the midaxillsry line. On table Flat plate of the abdomen showed the the undeformed bullet located on the right lobe of the liver.

= I told the surgeon to request a Lateral film! The bullet was located above the diaphram in the sinus with hemothorax. Chest tube and elective surgery.

= How about Pres. Ronald Reagan. They did an unnecessary Minilaparotomy with negative blood intra-abdominaly.

Did they do a Lateral cross table film? The bullet was never in the abdomen but was lodged in the left lower lobe it was reported in the papers. He was hit on the left thorax at the ancillary line.

= An accurate CLINICAL anatomical picture is a must, specially if you were to decide on surgical action!

.....well...we do not know a lot of info and many questions as pointed out above remain unanswered. Dr. Okugbo is the one who has centered the problem inherent to that pt.

The presentation was unsatisfactory in many aspects. You were asking what was the problem, what was missed, and for which reasons he died.

In absence of complete information, to make a meaningful discussion, even if retrospective - I just run into this Q by chance now -, we should assume several steps were taken as opportune or due.

I am not referring to the repeated ECG, ECHO, CT, or the obsessive search for a CT in that contest of "deterioration of consciousness and circulation with normal blood gases", as reported, and with the exclusion of CV gross causes.

It may be queried, for example, about the initial ABGs results, as to the impact of that analgesia, or to the status of the pt before mech vent in particular whether already brain damaged by the consequences of hypercapnia on Oxygene levels or how normal was the NBE in the "good blood gases" - the pt dies after 3 days! - or if there was a central pulse with the "ECG regained for 3 min". These are all questions that spontaneously arise in your mind once read the case presentation.

SUO above is right though, all things in order, an embolic cerebral event is a good and realistic dg hypothesis as is brain damage from acute resp acidosis or a SIR from subclinical sepsis in a pt who died on the third day. The subxiphoid window is better to be forgotten........