Missile embolism


  • Also known as "bullet embolism"
  • Occurs when a bullet or bullet fragment enters the bloodstream.
  • Can be arterial (80%) or venous[1]
  • Usually a small-caliber, low velocity projectile.[1]
    • For this reason, incidence higher in non-military setting due to predominance of lower velocity projectiles
    • Incidence = 1.1% in recent combat operations[2]
Missile embolism.jpg

Clinical Features

  • Number of entry wounds do not match exit wounds
  • Location of bullet not consistent with predicted trajectory
  • Bullet within intravascular or cavity without evidence of adjacent direct tissue injury
  • Fluoroscopy showing foreign body move within vascular cavity
  • CXR showing blurred foreign body within cardiac silhouette

Differential Diagnosis

Missile embolism types

  • Intrapericardial foreign body
  • Systemic venous embolism
  • Right heart and pulmonary artery embolism
  • Pulmonary vein embolism
  • Left heart embolism
  • Coronary artery embolism
  • Paradoxical embolus (due to patent foramen ovale)


  • Need to maintain high index of suspicion, obtain full body radiography when indicated[1]
  • TEE/TTE if intrathoracic
  • Serial fluoroscopy, especially if intracardiac, but will not determine if buried in myocardium or free moving within cavity
  • FAST exam as reasonable supplement


  • Controversial - not all need to be removed
  • Refer to diagram / literature review references


  • Admit to trauma floor vs. ICU based on hemodynamic stability vs. risk of further embolism complication

See Also


  1. 1.0 1.1 1.2 Fernandez-Ranvier, Gustavo G. et al. Pulmonary artery bullet embolism—Case report and review. International Journal of Surgery Case Reports , Volume 4 , Issue 5 , 521 - 523
  2. Lu K et al. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med. 2015 Jul; 16(4): 489–496.