GSW to head causing pneumothorax?

[bbbrammer]

We ran a 46yom the other day that had a self-inflicted GSW to the right side of the head, and noticed that he had tracheal deviation to the left. When I put the tube in at 25cm we heard breath sounds on the right but not on the left (no gastric), so I backed the tube off twice until I wound up at 21cm. Every time I auscultated I heard good sounds on the right, but none on the left with no gastric sounds. The ETCO2 changed colors appropriately and the pts rhythm improved, but I didn't back the tube out anymore so I didn't pull it out of the trachea. I did also have misting in the tube with a small amount of bloody mucus.

I thought he might have had a pneumothorax (or even hemopneumothorax) since he did have tracheal dev. to the left, with no lung sounds on the left. (I didn't have a chance to asses hyperresonance since the flight crew took over care at this time to fly him out to the hosp.)

I was wondering if anyone out there has had a case or heard of a case where a gunshot headshot caused one of the lungs to collapse. I know theoretically it is possible with bullet fragments and all, but it seemed unlikely since it was small caliber (.22 I think) and it wasn't fragmenting ammo.

Thought I would get some opinions from some of you guys to see what you think it might have been.

[vs-eh?]

We ran a 46yom the other day that had a self-inflicted GSW to the right side of the head, and noticed that he had tracheal deviation to the left. When I put the tube in at 25cm we heard breath sounds on the right but not on the left (no gastric), so I backed the tube off twice until I wound up at 21cm. Every time I auscultated I heard good sounds on the right, but none on the left with no gastric sounds. The ETCO2 changed colors appropriately and the pts rhythm improved, but I didn't back the tube out anymore so I didn't pull it out of the trachea. I did also have misting in the tube with a small amount of bloody mucus.

I thought he might have had a pneumothorax (or even hemopneumothorax) since he did have tracheal dev. to the left, with no lung sounds on the left. (I didn't have a chance to asses hyperresonance since the flight crew took over care at this time to fly him out to the hosp.)

I was wondering if anyone out there has had a case or heard of a case where a gunshot headshot caused one of the lungs to collapse. I know theoretically it is possible with bullet fragments and all, but it seemed unlikely since it was small caliber (.22 I think) and it wasn't fragmenting ammo.

Thought I would get some opinions from some of you guys to see what you think it might have been.

If you are querying a tension pneumothorax on this patient, remember that tracheal deviation is a LATE sign and that tracheal deviation goes toward the UNaffected side...

Hypotension would have been PRONOUNCED in this patient (if they were still alive and indeed had a pneumo), and is significantly more important for clinical determination.

Do people actually check hyperessonence in these cases (or at all)?

[Ridryder 911]

My guess is that a fragment or bullet tumbled down into sinus- post-pharynx area. This route could had lead into the esophageal puncture, upper lung. Remember, those bullets (especially in head wounds) may travel into several areas.

I agree V.S, most of the time one will see tracheal deviation, mediastinal shift to occur to move internal organs such as the heart, and trachea.. which is a lot of pressure. I have seen very many tracheal deviation on dead people...

I do attempt to check for tympani sounds to differentiate between hemo vs. pneumo, this will make my treatment regime from placing decompression from MCL to mid-ax. Air can escape upper, but with a hemo, I prefer mid-ax to allow to drain if possible.

R/r 911

[Richard B the EMT]

BLS logging in on this one.

Could it just be a coincidence of a spontaneous pneumothorax, at the same time as that Gun Shot Wound to the head?

[VDCavey]

Maybe overthinking but could it be related to the shock wave from the weapon?

[Thunderchild145]

Could be something other than pnuemothorax too. I've had pneumonia patients so bad you couldn't hear anything.

I'm not saying this is pnuemonia. That doesn't make any sense. Just saying to keep an open mind. =)

[fiznat]

Trach deviation to the left AND no sounds on the left? Weird.

Obviously when intubating and you dont hear sounds on the left you think right mainstem but it sounds like you thought about that.. I looked up tracheal deviation quickly on google and found a list of differentials:

# Pleural effusion

# Pneumothorax

# Pulmonary fibrosis

# Lung cancer

# Pulmonary collapse

# Surgical removal of a part of the lung

# Atelectasis

# Hitatal hernia

# Kyphoscoliosis

# Mediastinal tumor

# Pulmonary tuberculosis

# Retrosternal thyroid

# Tension pneumothorax

# Thoracic aortic aneurysm

You know more about the patient's history/presentation than we do: any of these stand out?

[bbbrammer]

Any of the pneumo's stand out, as well as possibly pulmonary collapse. The only hx we got on this pt. was from the family that said "the last time he did this he was on drugs". So unknown drug usage is about it. He is a little old for a spontaneous pneumo, and as fiznat commented, very weird that all the problems were on the left side. I know deviation usually goes to the opposite side, but I am at a loss to explain what else might be going on. That is why I thought I would try to get some input from some of you guys.

This guy was just different all together. He shot himself at some unknown time out in the woods, and when SWAT finally brought him out I thought he would be DOA. I couldn't believe it when they put him on my stretcher and I had a carotid pulse. When I got him on the monitor he actually had a Sinus Brady rhythm at about 44bpm until I tubed him, then it went to about 94bpm. His BP was 60/P, no PMS, hypothermic (91.5F), pupils dilated, skin cold, pale, dry. Like ridryder said, I have heard about bullet fragments traveling and collapsing a lung, but EVERYTHING was on the left side. Weird enough that I am having trouble explaining it. Any other thoughts?

PS: the guy was about 6'2" and 230lbs. That is why I didn't want to back the tube out past 21cm. Would you have kept backing it out, or just let it stay there at that depth?

[Spock]

An endo tube at 25 cm is probably in the right mainstem no matter how tall. At 74 inches I would not have the tube at anything less than 21 cm. The pneumothorax might have been caused by pressure against a closed glottic opening. He held his breath, pulled the trigger and the shock wave traveled downwards against the thorax. With the glottic opening closed there was no way to release the pressure other than a pneumothorax.

If that doesn't make any sense please feel free to tear it apart because it is the only thing I can think of.

Live long and prosper.

Spock

[JPINFV]

If the bullet was a .22 then there is a possibility that it traveled. The problem with small caliber bullet is that there is a chance of it not penetrating fully. While Googling (I'll post it below), there was a case of a patient who was shot several times including one bullet lodging in his bladder. After they removed the foley he passed the bullet spontaneously. While I don't know how much pressure is needed to pop a lung, I doubt that the pressure wave from a 0.22 will be enough to do so.