22yo male was accidentally shot with a pellet gun while hunting with his brother! There were multiple external pellet wounds to his face anterior chest and abdomen. He was haemodynamically stable with 100% sats. Abdomen was soft and NT. ECG was SR with no irregularities. A plain CT chest and abdomen was ordered. EFAST was not done due to clinical stability and as he was due to have CT imaging.
Reviewing the CT chest: Matt and Lisa had a freak out moment when one of the pellets was located perilously close to the heart. A frantic call to the radiologist was slightly reassuring: the pellet seemed to be in the epicardial fat. However a contrast CT was organised to make sure.
coronal CT image of the chest showing an opaque pellet inferior to the heart.
However, ED cardiac US revealed something very different!
The initial parasternal long axis view was reassuring. There was a tiny pericardial effusion and a normal RV and LV.
If anything, the radiology report appears to be correct. A bit of angling reveals a reverberation articfact seemingly anterior to the RV.
Parasternal long axis view showing a reverberation artefact anterior to the RV (see below).
Parasternal long axis view showing the commet artefact anterior to the RV (red arrow). This is produced by small highly reflective structures such as metal or air. This was assumed to be the pellet.
However, the subcostal view was slightly more scary
Subcostal view of the heart clearly showing the origin of the reverberation artefact within the RV myocardium. Below is a still of the cine loop with the artefact highlighted in blue.
Subcostal short axis view showing this more clearly.
Zoomed in view of the RV in short axis.
Contrast CT revealed that the pellet was in the RV myocardium. However as there was minimal pericardial effusion and as the patient was stable this was treated conservatively. Repeat formal TTE revealed no change in the position of the pellet.