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Can a Falling Bullet Be Lethal at Terminal Velocity? Cardiac Injury Caused by a Celebratory Bullet
Can a Falling Bullet Be Lethal at Terminal Velocity? Cardiac Injury Caused by a Celebratory Bullet Angelo N. Incorvaia, MD, Despina M. Poulos, MPH, Robert N. Jones, MD, and James M. Tschirhart, MD Synergy Medical Education Alliance, and Department of Cardiothoracic Surgery, Michigan Cardiovascular Institute, and Department of General Surgery, Covenant Healthcare, Michigan State University, East Lansing, Michigan
This is a case report of rare cardiac and abdominal organ injuries sustained by an innocent bystander from a New Year’s Eve celebratory gun shooting. The force and velocity of a projectile fired into the air as it ascends and returns to earth, along with its potential for bodily injury will be reviewed. (Ann Thorac Surg 2007;83:283– 4) © 2007 by The Society of Thoracic Surgeons
T
his case reports injuries sustained by an innocent bystander from a New Year’s Eve celebratory gunshot. The International Classification of Diseases defines a probable celebratory gunfire injury as an unintentional firearm injury inflicted outdoors by an unidentified assailant [1]. It is not unusual for law-abiding citizens to celebrate New Year’s Eve and Independence Day by shooting their guns into the air, despite it being both illegal and dangerous [2]. News media reports from around the world suggest that celebratory gunfire injuries from spent bullets are indeed a widespread public health problem, and the morbidity and mortality of these injuries are dependent on the number of hits the patient received, the anatomical location of the injury, and the severity of the wound itself. This case discusses the surgical management of a patient struck by a celebratory bullet and the rarity of the injuries he sustained. A 47-year-old white man was struck in the chest by a bullet that fell from the sky while watching fireworks on New Year’s Eve. The patient arrived shortly after into the emergency department. He complained of chest pain and difficulty breathing, but he denied hemoptysis, dizziness, or any loss of consciousness. On initial physical examination he was hypotensive and diaphoretic with cyanosis. His blood pressure was 50/32, his pulse was 140 bpm, and his respiratory rate was 50 breaths per minute, with an oxygen saturation of 98% on 100% oxygen by nonrebreather face mask. There was a bullet hole in his chest on the left side above the nipple line, in the fifth intercostal space, 2 cm to the left of the sternal edge. Emergency tracheostomy secured his airway. Fluid resuscitation was achieved through an 8-French subclavian vein catheter. Accepted for publication April 14, 2006. Address correspondence to Dr Incorvaia, Beth Israel Hand Surgery Center, 321 West 34th Street, New York, NY 10016; e-mail: incorvaia@ gmail.com.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
On cardiac examination the patient was tachycardic with non-muffled heart sounds and no murmurs. His breath sounds were clear and equal bilaterally. His abdomen was nondistended, soft, and non-tender, with positive bowel sounds. A focused abdominal sonography for trauma and chest roentgenogram were both normal. An intravenous pyelogram excluded ureteral or renal collecting system injury, but did show a bullet (6 cm to the left of midline) at the level of second lumbar vertebrae (Fig 1). At celiotomy, there was blood in the peritoneal cavity and chyme extruding through a large hole in the lesser curvature of the stomach, temporarily controlled by placing of noncrushing clamps over the defect. Packing placed in the left upper abdominal quadrant provided hemostasis of the splenic hilum. There was a diaphragmatic perforation 5 cm to the left of the diaphragmatic crura. Digital probing of a bleeding hole in the diaphragm confirmed a cardiac injury. Manual occlusion controlled bleeding from this hole while awaiting the arrival of the cardiothoracic team. The patient’s blood pressure trended downward, requiring an emergent median sternotomy. The pericardium bulged with blood, and on opening it, two holes were exposed in the right ventricle. His heart alternated between fibrillation and asystole for 15 minutes, during which time cardiac massage and internal defibrillation, while digitally plugging the holes maintained perfusion. On arrival of the cardiothoracic team, cardiopulmonary bypass allowed for the repair of the cardiotomies with a dacron patch of interrupted absorbable sutures provided for a secure repair of the diaphragmatic injury. After closing the sternum and overlying skin, we explored the abdomen. The patient had a splenectomy for a splenic hilum injury, due to the impact of the bullet. Although the bullet did not directly hit the spleen, the posterior stomach adjacent to the splenic hilum was contused and partially torn. There was an entrance wound at the lesser curvature and a contusion of the greater curvature adjacent to the spleen. A second gastrotomy positioned in the posterior stomach was used to decompress it while protecting the sternal incision from contamination. The .45-caliber bullet found within the stomach was not deformed. Staples allowed for quick closure of both gastrotomies. Closed suction catheters, drained the space around the stomach. Estimated blood loss was 5,500 mL throughout the 9-hour procedure. Thirty days postoperatively the patient recovered without infection and walked out the front door of the hospital in stable condition after discharge.
Comment The scientific literature reports incidences of celebratory firing as a major public health concern internationally. In Kuwait, after the end of the Gulf War, the Kuwaitis celebrated by firing weapons into the air—and 20 Kuwaitis died from falling bullets [3]. In Los Angeles, 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.04.046
FEATURE ARTICLES
CASE REPORTS
284
CASE REPORT LAMARCHE ET AL COREVALVE PERCUTANEOUS AORTIC VALVE
Ann Thorac Surg 2007;83:284 –7
FEATURE ARTICLES
patients who have sustained head wounds from celebratory fire [2]. Data show the 77% of reported celebratory firing results in injury to the head, 12% to the shoulder, 5% to the upper back, 2% to the posterior chest and neck, respectively, and 1% to the upper arm, leg, and foot each [2]. Of the 2% of the bullets hitting their victims in the chest, only a fraction of those injure the heart. Although the bullets falling at terminal velocity are traveling slowly, relative to their initial muzzle velocity, they do travel fast enough to cause significant injury and death. Considering these injuries as low velocity ones, assuming the bullet does not have enough energy to do more than penetrate the skin is ill-advised. Underestimating the magnitude of force of these projectiles can be detrimental to the patient’s management and outcome. This case is evidence to the kinetic energy a celebratory bullet can have, injuring two body cavities and four organs, including the heart, diaphragm, stomach, and spleen. On laparotomy, where a thoracic gunshot wound results in a projectile in the abdominal cavity, the diaphragmatic injury should be explored with the cardiothoracic team involved or readily available.
References
Fig 1. One-shot intravenous pyelogram shows intact bullet in left upper abdominal quadrant with no injury to renal collecting systems.
between the years 1985 and 1992, doctors treated 118 people for random falling-bullet injuries at King/Drew Medical Center, and 38 of them died [2]. Practically all of the injuries were due to happy holiday weekend revelers [3]. Bullets fired into the air during celebrations return at a speed fast enough to penetrate the skin and cause internal damage to other organs in the path of the migrating bullet. The bullet’s velocity required for skin penetration is between 148 and 197 feet per second. A velocity of less than 200 feet per second, which is easily obtained by a celebratory gunfire, is capable of fracturing bone and even causing intracranial penetration [4]. Spent bullets have the capability of reaching up to 600 feet per second during their downfall, and thus they have the ability to inflict damage to multiple body cavities [4]. The larger caliber bullets (ie, .45-caliber) reach a higher terminal velocity compared with the smaller caliber bullets (ie, .30-caliber), because of the proportion of their weight to their diameter [4]. Terminal velocity is difficult to calculate with falling bullets because wind resistance and updrafts can cause a spent bullet to land miles away from the initially fired site [2]. Celebratory gunshots perforating through and through injuries to the chest occur in less than 3% of total celebratory injuries [2]. The documented morbidity and mortality for celebratory chest injuries is each 50%, which is similar to the 80% morbidity and 40% mortality rate of © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. World Health Organization. International Statistical classification of diseases and related health problem, 10th revision. Geneva, Switzerland: World Health Organization, 1992. 2. Ordog GJ, Dornhoffer P, Ackroyd G, et al. Spent bullets and their injuries: the result of firing weapons into the sky. J Trauma 1994;37:1003– 6. 3. Centers for Disease Control and Prevention. New Year’s Eve injuries caused by celebratory gunfire—Puerto Rico, 2003. MMWR 2004;53:1174 –5. 4. Ordog GJ, Wasserberger J, Balasubramanium S. Wound ballistics: theory and practice. Ann Emerg Med 1985;13:1113.
Implantation of the CoreValve Percutaneous Aortic Valve Yoan Lamarche, MD, Raymond Cartier, MD, André Y. Denault, MD, Arsène Basmadjian, MD, Colin Berry, MD, PhD, Jean-Claude Laborde, MD, and Raoul Bonan, MD Departments of Surgery, Anesthesiology, and Cardiology, Montréal Heart Institute and “Université de Montréal,” Montréal, Québec, Canada, and Department of Cardiology, Clinique Pasteur, Toulouse, France
Surgical aortic valve replacement is the only recommended treatment for significant aortic valve stenosis. Percutaneous aortic valve replacement appears to be a novel option for high-risk patients. We report the implantation of the ReValving system (CoreValve, Paris, France) in a 64-year-old woman who was refused aortic valve replacement surgery for critical aortic stenosis and Accepted for publication May 31, 2006. Address correspondence to Dr Bonan, Department of Medicine, Montréal Heart Institute, 5000 Belanger St, Montréal, Québec H1T1C8, Canada; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.121
This is a case report of rare cardiac and abdominal organ injuries sustained by an innocent bystander from a New Year’s Eve celebratory gun shooting. The force and velocity of a projectile fired into the air as it ascends and returns to earth, along with its potential for bodily injury will be reviewed. (Ann Thorac Surg 2007;83:283– 4) © 2007 by The Society of Thoracic Surgeons
T
his case reports injuries sustained by an innocent bystander from a New Year’s Eve celebratory gunshot. The International Classification of Diseases defines a probable celebratory gunfire injury as an unintentional firearm injury inflicted outdoors by an unidentified assailant [1]. It is not unusual for law-abiding citizens to celebrate New Year’s Eve and Independence Day by shooting their guns into the air, despite it being both illegal and dangerous [2]. News media reports from around the world suggest that celebratory gunfire injuries from spent bullets are indeed a widespread public health problem, and the morbidity and mortality of these injuries are dependent on the number of hits the patient received, the anatomical location of the injury, and the severity of the wound itself. This case discusses the surgical management of a patient struck by a celebratory bullet and the rarity of the injuries he sustained. A 47-year-old white man was struck in the chest by a bullet that fell from the sky while watching fireworks on New Year’s Eve. The patient arrived shortly after into the emergency department. He complained of chest pain and difficulty breathing, but he denied hemoptysis, dizziness, or any loss of consciousness. On initial physical examination he was hypotensive and diaphoretic with cyanosis. His blood pressure was 50/32, his pulse was 140 bpm, and his respiratory rate was 50 breaths per minute, with an oxygen saturation of 98% on 100% oxygen by nonrebreather face mask. There was a bullet hole in his chest on the left side above the nipple line, in the fifth intercostal space, 2 cm to the left of the sternal edge. Emergency tracheostomy secured his airway. Fluid resuscitation was achieved through an 8-French subclavian vein catheter. Accepted for publication April 14, 2006. Address correspondence to Dr Incorvaia, Beth Israel Hand Surgery Center, 321 West 34th Street, New York, NY 10016; e-mail: incorvaia@ gmail.com.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
On cardiac examination the patient was tachycardic with non-muffled heart sounds and no murmurs. His breath sounds were clear and equal bilaterally. His abdomen was nondistended, soft, and non-tender, with positive bowel sounds. A focused abdominal sonography for trauma and chest roentgenogram were both normal. An intravenous pyelogram excluded ureteral or renal collecting system injury, but did show a bullet (6 cm to the left of midline) at the level of second lumbar vertebrae (Fig 1). At celiotomy, there was blood in the peritoneal cavity and chyme extruding through a large hole in the lesser curvature of the stomach, temporarily controlled by placing of noncrushing clamps over the defect. Packing placed in the left upper abdominal quadrant provided hemostasis of the splenic hilum. There was a diaphragmatic perforation 5 cm to the left of the diaphragmatic crura. Digital probing of a bleeding hole in the diaphragm confirmed a cardiac injury. Manual occlusion controlled bleeding from this hole while awaiting the arrival of the cardiothoracic team. The patient’s blood pressure trended downward, requiring an emergent median sternotomy. The pericardium bulged with blood, and on opening it, two holes were exposed in the right ventricle. His heart alternated between fibrillation and asystole for 15 minutes, during which time cardiac massage and internal defibrillation, while digitally plugging the holes maintained perfusion. On arrival of the cardiothoracic team, cardiopulmonary bypass allowed for the repair of the cardiotomies with a dacron patch of interrupted absorbable sutures provided for a secure repair of the diaphragmatic injury. After closing the sternum and overlying skin, we explored the abdomen. The patient had a splenectomy for a splenic hilum injury, due to the impact of the bullet. Although the bullet did not directly hit the spleen, the posterior stomach adjacent to the splenic hilum was contused and partially torn. There was an entrance wound at the lesser curvature and a contusion of the greater curvature adjacent to the spleen. A second gastrotomy positioned in the posterior stomach was used to decompress it while protecting the sternal incision from contamination. The .45-caliber bullet found within the stomach was not deformed. Staples allowed for quick closure of both gastrotomies. Closed suction catheters, drained the space around the stomach. Estimated blood loss was 5,500 mL throughout the 9-hour procedure. Thirty days postoperatively the patient recovered without infection and walked out the front door of the hospital in stable condition after discharge.
Comment The scientific literature reports incidences of celebratory firing as a major public health concern internationally. In Kuwait, after the end of the Gulf War, the Kuwaitis celebrated by firing weapons into the air—and 20 Kuwaitis died from falling bullets [3]. In Los Angeles, 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.04.046
FEATURE ARTICLES
CASE REPORTS
284
CASE REPORT LAMARCHE ET AL COREVALVE PERCUTANEOUS AORTIC VALVE
Ann Thorac Surg 2007;83:284 –7
FEATURE ARTICLES
patients who have sustained head wounds from celebratory fire [2]. Data show the 77% of reported celebratory firing results in injury to the head, 12% to the shoulder, 5% to the upper back, 2% to the posterior chest and neck, respectively, and 1% to the upper arm, leg, and foot each [2]. Of the 2% of the bullets hitting their victims in the chest, only a fraction of those injure the heart. Although the bullets falling at terminal velocity are traveling slowly, relative to their initial muzzle velocity, they do travel fast enough to cause significant injury and death. Considering these injuries as low velocity ones, assuming the bullet does not have enough energy to do more than penetrate the skin is ill-advised. Underestimating the magnitude of force of these projectiles can be detrimental to the patient’s management and outcome. This case is evidence to the kinetic energy a celebratory bullet can have, injuring two body cavities and four organs, including the heart, diaphragm, stomach, and spleen. On laparotomy, where a thoracic gunshot wound results in a projectile in the abdominal cavity, the diaphragmatic injury should be explored with the cardiothoracic team involved or readily available.
References
Fig 1. One-shot intravenous pyelogram shows intact bullet in left upper abdominal quadrant with no injury to renal collecting systems.
between the years 1985 and 1992, doctors treated 118 people for random falling-bullet injuries at King/Drew Medical Center, and 38 of them died [2]. Practically all of the injuries were due to happy holiday weekend revelers [3]. Bullets fired into the air during celebrations return at a speed fast enough to penetrate the skin and cause internal damage to other organs in the path of the migrating bullet. The bullet’s velocity required for skin penetration is between 148 and 197 feet per second. A velocity of less than 200 feet per second, which is easily obtained by a celebratory gunfire, is capable of fracturing bone and even causing intracranial penetration [4]. Spent bullets have the capability of reaching up to 600 feet per second during their downfall, and thus they have the ability to inflict damage to multiple body cavities [4]. The larger caliber bullets (ie, .45-caliber) reach a higher terminal velocity compared with the smaller caliber bullets (ie, .30-caliber), because of the proportion of their weight to their diameter [4]. Terminal velocity is difficult to calculate with falling bullets because wind resistance and updrafts can cause a spent bullet to land miles away from the initially fired site [2]. Celebratory gunshots perforating through and through injuries to the chest occur in less than 3% of total celebratory injuries [2]. The documented morbidity and mortality for celebratory chest injuries is each 50%, which is similar to the 80% morbidity and 40% mortality rate of © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. World Health Organization. International Statistical classification of diseases and related health problem, 10th revision. Geneva, Switzerland: World Health Organization, 1992. 2. Ordog GJ, Dornhoffer P, Ackroyd G, et al. Spent bullets and their injuries: the result of firing weapons into the sky. J Trauma 1994;37:1003– 6. 3. Centers for Disease Control and Prevention. New Year’s Eve injuries caused by celebratory gunfire—Puerto Rico, 2003. MMWR 2004;53:1174 –5. 4. Ordog GJ, Wasserberger J, Balasubramanium S. Wound ballistics: theory and practice. Ann Emerg Med 1985;13:1113.
Implantation of the CoreValve Percutaneous Aortic Valve Yoan Lamarche, MD, Raymond Cartier, MD, André Y. Denault, MD, Arsène Basmadjian, MD, Colin Berry, MD, PhD, Jean-Claude Laborde, MD, and Raoul Bonan, MD Departments of Surgery, Anesthesiology, and Cardiology, Montréal Heart Institute and “Université de Montréal,” Montréal, Québec, Canada, and Department of Cardiology, Clinique Pasteur, Toulouse, France
Surgical aortic valve replacement is the only recommended treatment for significant aortic valve stenosis. Percutaneous aortic valve replacement appears to be a novel option for high-risk patients. We report the implantation of the ReValving system (CoreValve, Paris, France) in a 64-year-old woman who was refused aortic valve replacement surgery for critical aortic stenosis and Accepted for publication May 31, 2006. Address correspondence to Dr Bonan, Department of Medicine, Montréal Heart Institute, 5000 Belanger St, Montréal, Québec H1T1C8, Canada; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.121