Expectoration of a bullet after gunshot wound to the chest
We report the case of a 24-year-old male who sustained a gunshot wound to his left shoulder. He presented to the emergency department with a primary complaint of shoulder pain and difficulty in swallowing. On primary survey, the airway was patent and he was hemodynamically stable. A single bullet wound was visualized above the left scapula. On chest radiograph, the bullet was located in the left pulmonary hilum near the mainstem bronchus []. No pneumothorax or hemothorax were apparent; this was confirmed with the radiologist. At this point, the patient complained of increasing difficulty in swallowing and was intubated for airway protection. An orogastric tube was passed erroneously into the airway precipitating vigorous coughing and eventual vomiting of gastric contents. Once this was properly replaced, the patient underwent CT angiography (CTA) of the chest and flexible bronchoscopy. CTA revealed no vascular injury; however, air was present throughout the mediastinum and the subcutaneous tissues of the anterior neck []. The bullet was again seen near the left mainstem bronchus []. There was no pneumothorax or hemothorax. After discussion with our radiologist, we believed that the bullet had likely caused a small airway injury which had quickly sealed, leading to the pneumomediastinum without evidence of pneumothorax or bronchopleural fistula. Flexible bronchoscopy revealed no blood or bullet fragments, but only a small abrasion in the left posterolateral trachea which was thought, at the time, to be due to trauma from the initial orogastric tube placement.\nAs no significant injuries were noted on initial bronchoscopy, the patient continued to be managed nonoperatively. In light of there being no pneumo- or hemothorax, the presumed trajectory of the bullet was from above the left scapula directly to the left pulmonary hilum. Based on this, it was felt that he was at low risk for esophageal injury, and gastrointestinal endoscopy was deferred. He remained intubated, afebrile, and hemodynamically stable. A second bronchoscopy by a thoracic surgeon was performed on hospital day 2 which again revealed only the small abrasion. He was extubated on day 3 and started on a regular diet. That night, the patient reported a ticklish sensation in the back of his throat and proceeded to sneeze, expectorating the bullet. Repeat chest radiograph confirmed that the bullet was no longer present in the chest.