Missile embolus: Difference between revisions

(Same)
 
No edit summary
Line 1: Line 1:
=== Definition ===
==Background==
Missle Embolization is an umbrella term encompassing the intravasculature and intracardiac embolization of bullet fragments, pellets, and shrapnel most commonly from war related penetrating traumas (mortars, grenades, mines, etc.)<ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>.  
*Missle Embolization is an umbrella term encompassing the intravasculature and intracardiac embolization of bullet fragments, pellets, and shrapnel most commonly from war related penetrating traumas (mortars, grenades, mines, etc.)<ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>.  
*A rare phenomenon with the majority of cases occurring in war/combat penetrating trauma, although civilian cases have been reported <ref name="variedpres"> Aidinian, G., Fox, C. J., Rasmussen, T. E., & Gillespie, D. L. (2010). Varied presentations of missile emboli in military combat. Journal of Vascular Surgery, 51(1), 214–217. http://doi.org/10.1016/j.jvs.2009.06.054 </ref>. 
*Definitive recommendations regarding management and treatment are varied. 


=== Background ===
==Clinical Features==
Missile Embolization is a rare phenomenon with the majority of cases occurring in war/combat penetrating trauma, although civilian cases have been reported <ref name="variedpres"> Aidinian, G., Fox, C. J., Rasmussen, T. E., & Gillespie, D. L. (2010). Varied presentations of missile emboli in military combat. Journal of Vascular Surgery, 51(1), 214–217. http://doi.org/10.1016/j.jvs.2009.06.054 </ref>. While there are several case reviews available in the current literature, definitive recommendations regarding management and treatment are varied.  However, a review of the literature reveals a commonly used algorithm for clinical recognition, diagnostic evaluation, and management/treatment of patients with missile embolization <ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>. 
*Commonly present with asymmetric peripheral pulses, evidence of metallic fragments remote from the site of penetrating injury (outside of the expected fragment trajectory), and lack of an exit wound <ref name="variedpres"> Aidinian, G., Fox, C. J., Rasmussen, T. E., & Gillespie, D. L. (2010). Varied presentations of missile emboli in military combat. Journal of Vascular Surgery, 51(1), 214–217. http://doi.org/10.1016/j.jvs.2009.06.054 </ref>.  
*However, patient presentation can vary, and hemodynamically stable vital signs, lack of penetrating trauma on a pulseless extremity, and the presence of an exit wound should not be used to exclude the diagnosis.
*As delayed and occult arterial injury have been reported in the literature


 
===Arterial Missile Emboli Complications <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>===
=== Recognition ===
The emergency medicine physician should have a high incidence of suspicion for any patient with penetrating trauma as up to 5% of arterial injuries may be missed on the initial CT angiogram in patients with fragmentation wounds <ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>. Commonly, patients present with asymmetric peripheral pulses, evidence of metallic fragments remote from the site of penetrating injury (outside of the expected fragment trajectory), and lack of an exit wound <ref name="variedpres"> Aidinian, G., Fox, C. J., Rasmussen, T. E., & Gillespie, D. L. (2010). Varied presentations of missile emboli in military combat. Journal of Vascular Surgery, 51(1), 214–217. http://doi.org/10.1016/j.jvs.2009.06.054 </ref>. However patient presentation can vary, and hemodynamically stable vital signs, lack of penetrating trauma on a pulseless extremity, and the presence of an exit wound should not be used to exclude the diagnosis.
 
As delayed and occult arterial injury have been reported in the literature, patients should be monitored for changing vital signs and/or evidence of traveling retained fragments on serial imaging. 
 
=== Diagnostic Evaulation ===
As the majority of patients with penetrating trauma receive initial radiographic imaging (including a eFAST exam), the physician can begin by looking for evidence of metallic foreign bodies both near and far from the site of penetrating injury.  If clinically indicated, a chest xray should be obtained as missiles within the systemic venous circulation carry the risk of embolizing to the pulmonary artery.
 
After initial chest xrays are obtained, further imaging is guided by the location of the suspected missile fragment. If there is evidence of intracardiac or intrapulmonary foreign bodies, a CT chest/abdomen/pelvis with IV contrast is helpful in determining missile trajectory, size, and exact location.  A 2D transesophageal echocardiogram is also recommended for intrathoracic missiles <ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>.  If there is evidence of extremity foreign body (especially with diminished or absent pulses), a CT angiogram of the involved extremity is necessary to guide further surgical management. 
 
=== Complications of Retained Missile Emboli ===
Arterial Missile Emboli Complications <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>:
*Distal ischemia
*Distal ischemia
*Thrombosis
*Thrombosis
*Further embolization.
*Further embolization


Venous Missile Emboli Complications:
===Venous Missile Emboli Complications===
*Pulmonary artery embolism
*Pulmonary artery embolism
*Cardiac valve dysfunction  
*Cardiac valve dysfunction  
*Endocarditis
*[[Endocarditis]]
*Abscess formation
*[[Abscess]] formation
*Sepsis
*[[Sepsis]]
*Thrombosis
*Thrombosis
*Dysrhythmias
*[[Dysrhythmias]]
*Intraventricular communications
*Intraventricular communications
*Conduction defects
*Conduction defects
Line 35: Line 27:
*Hemorrhage
*Hemorrhage
*Cardiac ischemia from erosion into coronary vessels
*Cardiac ischemia from erosion into coronary vessels
*Thrombophlebitis
*[[Thrombophlebitis]]


Psychiatric Complications:
===Psychiatric Complications===
*Anxiety
*Anxiety
*Cardiac neurosis
*Cardiac neurosis
*Fear of movement resulting in a dislodgment of the missile from its current location
*Fear of movement resulting in a dislodgment of the missile from its current location


=== Management and Treatment ===
==Evaluation==
Most authors recommend the removal of symptomatic missile emboli.  However, since missile emboli can become dislodged as well as lead to other complications carrying high morbidity and mortality, they are commonly removed. Surgical management is case specific, but minimally invasive embolectomies are preferred if there is a high probability of missile retrieval <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>.  There is not strong evidence supporting prophylactic antibiotic use. However, patients with intracardiac emboli may benefit from 48 hours of a first generation cephalosporin to prevent endocarditis with the addition of an aminoglycoside for soft tissue cavitating injuries.  Patients with retained missiles who are not surgical candidates maybe benefit from 12 months of anticoagulation <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>.  
''Need high incidence of suspicion with penetrating trauma (up to 5% of arterial injuries may be missed on the initial CT angiogram in patients with fragmentation wounds) <ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>. ''
*[[CXR]]
*X-ray (location specific) and/or CT
**Look for evidence of metallic foreign bodies both near and far from the site of penetrating injury
*If there is evidence of intracardiac or intrapulmonary foreign bodies, consider:<ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>
**CT chest/abdomen/pelvis with IV contrast (to determin missile trajectory, size, and exact location)
**2D transesophageal echocardiogram is also recommended for intrathoracic missiles
**CT angiogram of the involved extremity, if evidence of extremity foreign body (e.g. diminished or absent pulses) 
 
==Management==
[[File:Wjem-16-489 copy 2.jpg ‎|thumbnail|Algorithm for Management of Missile Emboli based on Anatomic Location<ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>]]
*Remove symptomatic missile emboli
*Low threshold to remove asymptomatic missle emboli (since they can become dislodged and lead to other complications)
*Surgical management is case specific, but minimally invasive embolectomies are preferred if there is a high probability of missile retrieval <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>.   
*There is not strong evidence supporting prophylactic [[antibiotic]] use.
**However, patients with intracardiac emboli may benefit from 48 hours of a first generation [[cephalosporin]] to prevent endocarditis with the addition of an [[aminoglycoside ]]for soft tissue cavitating injuries.   
*Patients with retained missiles who are not surgical candidates maybe benefit from 12 months of anticoagulation <ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>.  


One literature review recommends the following algorithm for missile emboli based on location
=== Pitfalls in Management and Treatment<ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>.===
<ref name="litreview"> Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553 </ref>:
*Delayed recognition
[[File:Wjem-16-489 copy 2.jpg ‎|thumbnail|Algorithm for Management of Missile Emboli based on Anatomic Location]]
*Dislodgement of the missile during central venous catheter placements and/or inferior vena cava filters
*Repeated emobolization with patient reposition and surgical manipulation


=== Pitfalls in Management and Treatment ===
==Disposition==
Common pitfalls in the management and treatment of missile emboli involve delayed recognition; dislodgement of the missile during central venous catheter placements, and/or inferior vena cava filters; and repeated emobolization with patient reposition and surgical manipulation<ref name="pitfalls"> Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1 </ref>. 
*Admission


==See Also==


=== Sources ===
==References==
<references/>
<references/>

Revision as of 06:22, 2 August 2016

Background

  • Missle Embolization is an umbrella term encompassing the intravasculature and intracardiac embolization of bullet fragments, pellets, and shrapnel most commonly from war related penetrating traumas (mortars, grenades, mines, etc.)[1].
  • A rare phenomenon with the majority of cases occurring in war/combat penetrating trauma, although civilian cases have been reported [2].
  • Definitive recommendations regarding management and treatment are varied.

Clinical Features

  • Commonly present with asymmetric peripheral pulses, evidence of metallic fragments remote from the site of penetrating injury (outside of the expected fragment trajectory), and lack of an exit wound [2].
  • However, patient presentation can vary, and hemodynamically stable vital signs, lack of penetrating trauma on a pulseless extremity, and the presence of an exit wound should not be used to exclude the diagnosis.
  • As delayed and occult arterial injury have been reported in the literature

Arterial Missile Emboli Complications [3]

  • Distal ischemia
  • Thrombosis
  • Further embolization

Venous Missile Emboli Complications

Psychiatric Complications

  • Anxiety
  • Cardiac neurosis
  • Fear of movement resulting in a dislodgment of the missile from its current location

Evaluation

Need high incidence of suspicion with penetrating trauma (up to 5% of arterial injuries may be missed on the initial CT angiogram in patients with fragmentation wounds) [1].

  • CXR
  • X-ray (location specific) and/or CT
    • Look for evidence of metallic foreign bodies both near and far from the site of penetrating injury
  • If there is evidence of intracardiac or intrapulmonary foreign bodies, consider:[1]
    • CT chest/abdomen/pelvis with IV contrast (to determin missile trajectory, size, and exact location)
    • 2D transesophageal echocardiogram is also recommended for intrathoracic missiles
    • CT angiogram of the involved extremity, if evidence of extremity foreign body (e.g. diminished or absent pulses)

Management

Algorithm for Management of Missile Emboli based on Anatomic Location[1]
  • Remove symptomatic missile emboli
  • Low threshold to remove asymptomatic missle emboli (since they can become dislodged and lead to other complications)
  • Surgical management is case specific, but minimally invasive embolectomies are preferred if there is a high probability of missile retrieval [3].
  • There is not strong evidence supporting prophylactic antibiotic use.
    • However, patients with intracardiac emboli may benefit from 48 hours of a first generation cephalosporin to prevent endocarditis with the addition of an aminoglycoside for soft tissue cavitating injuries.
  • Patients with retained missiles who are not surgical candidates maybe benefit from 12 months of anticoagulation [3].

Pitfalls in Management and Treatment[3].

  • Delayed recognition
  • Dislodgement of the missile during central venous catheter placements and/or inferior vena cava filters
  • Repeated emobolization with patient reposition and surgical manipulation

Disposition

  • Admission

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 Lu, K., Gandhi, S., Qureshi, M., Wright, A., Kantathut, N., & Noeller, T. (2015). Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. Western Journal of Emergency Medicine, 16(4), 489–496. http://doi.org/10.5811/westjem.2015.5.25553
  2. ↑ 2.0 2.1 Aidinian, G., Fox, C. J., Rasmussen, T. E., & Gillespie, D. L. (2010). Varied presentations of missile emboli in military combat. Journal of Vascular Surgery, 51(1), 214–217. http://doi.org/10.1016/j.jvs.2009.06.054
  3. ↑ 3.0 3.1 3.2 3.3 Singer, R. L., Dangleben, D. A., Salim, A., Kurek, S. J., Shah, K. T., Goodreau, J. J., … Szydlowski, G. W. (2003). Missile Embolism to the Pulmonary Artery: Case Report and Pitfalls of Management. Annals of Thoracic Surgery, 76(5), 1722–1725. http://doi.org/10.1016/S0003-4975(03)00692-1
Retrieved from "https://www.wikem.org/w/index.php?title=Missile_embolus&oldid=92288"