Russell Nicole, Vieira Ethan J, Freeman Lexi R, Eastman Alexander L, Khan Uzer, Schluterman Haley M, Beakes Caroline, Kirkpatrick Sioned, Grant Jennifer L
Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Texas, USA.
Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
Trauma Surg Acute Care Open. 2024 Jul 11;9(1):e001390. doi: 10.1136/tsaco-2024-001390. eCollection 2024.
Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients.
An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization.
A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge.
Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.
弹道栓塞（BE）是火器伤的一种罕见并发症，在创伤病房中常伴有令人困扰的临床表现。除非早期考虑到，否则相关的混淆可能导致对枪伤患者的治疗不必要地延迟。尽管存在这种已知情况，但关于这些患者并发症、治疗和随访的高级别证据相对较少。
进行电子数据库文献检索，以识别在首次住院期间发生的儿童和成人平民急性血管内BE病例，筛选过去10年的出版物。排除标准包括非血管栓塞、军事环境中发生的损伤以及定义为首次住院出院后发生的延迟迁移。
共分析了136例病例。几乎所有BE病例均在就诊后48小时内发生。与静脉栓塞相比，动脉栓塞出现症状的可能性显著更高（71%对7%，p<0.001），43%的患者在创伤病房出现了与BE相关的症状。此外，动脉栓塞采用非侵入性治疗的可能性显著更低（19%对49%，p<0.001）。与血管内尝试相比，开放取出成功的可能性显著更高（91%对29%，p<0.001）。动脉栓塞患者更有可能接受随访（52%对39%），住院期间任何取出尝试与门诊随访显著相关（p=0.034）。除1例患者外，所有患者出院后均保持稳定或症状有临床改善。
对于任何有新的或持续的无法解释的体征或症状的患者，尤其是在穿透性火器伤后的头48小时内，考虑BE是合理的。虽然静脉BE通常可以安全观察，但动脉BE一般需要紧急取出。采用非侵入性治疗的患者可能在受伤后的第一年随访中受益。
