238 Short report Cardial gunshot injury: treatment in a trauma hospital without a cardiac unit Maximilian Faschingbauer, Arndt P. Schulz and Christian Ju ¨ rgens Gunshot injuries to the chest often require urgent admission to the nearest hospital, because of the cardiorespiratory status, transfer to a hospital without a cardiothoracic unit might be unsafe. In this case, a male patient was transferred to the nearest hospital on being shot through the heart. On admission, he was in shock, and immediate surgery was performed. We report our treatment regime for thoracic injuries and the specific management of this patient. We conclude that every hospital with an accident and emergency department has to be prepared for such an injury and that operative management is possible without cardiopulmonary bypass. European Journal of Emergency Medicine 13:238–241  c 2006 Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2006, 13:238–241 Keywords: cardiac injury, gunshot wound, heart injury, penetrating trauma, sternotomy, thoracic injury Correspondence and requests for reprints to Maximilian Faschingbauer, Department of Trauma and Orthopaedic Surgery, BG Trauma Hospital Hamburg, Bergedorfer Strasse 10, 21027 Hamburg, Germany Tel: +49 40 7306 2450; fax: +49 40 7306 2406; e-mail: m.faschingbauer@buk-hamburg.de Received 25 April 2005 Accepted 2 February 2006 Introduction Compared with other parts of the world, firearm injuries are relatively rare in western Europe. Nevertheless, the incidence is increasing, as is the availability of disused firearms of the former soviet forces in Germany [1]. If a gunshot injury to the chest occurs, swift investigations and management are needed. Cardiorespiratory status often demands rapid transfer to the nearest hospital, irrespective of whether this has a cardiothoracic unit. In the haemodynamically unstable patient, immediate operative intervention is necessary with no time for any investigations. These injuries often involve main intrathoracic vessels or mediastinal structures. We report the case of a 43-year-old male who sustained a transcardial gunshot injury. Our hospital is a trauma centre that acts as a tertiary referral hospital for Hamburg and surrounding areas for general trauma and orthopaedics. Burn injuries, spinal injuries and polytraumatized patients are referred from the whole of northern Germany. As there is no cardiovascular unit in our hospital, injuries involving the heart or the thoracic aorta are normally transferred to a cardiothoracic unit. Other vascular injuries are treated in our unit by a consultant vascular surgeon based in a nearby hospital. In blunt or sharp thoracic trauma, our guideline is to perform resuscitation according to Advanced Trauma Life Support guidelines, followed by chest X-ray. In the stable patient we then perform tube thoracostomy, if necessary, followed by helical-computed tomography (CT) scan. Indications for theatre transferral are then dictated by the findings on the CT scan or if there are signs of massive haemorrhage. Otherwise the patient is transferred to intensive therapy unit where other specific investigations are then organized as required (e.g. bronchoscopy, Gastrografin-swallow) (Gastrografin, Schering AG, Berlin, Germany). Case study The 43-year-old Caucasian male victim was admitted via a doctor-equipped ambulance directly to our emergency unit. He was transferred after the insertion of a large bore intravenous-access and after starting fluid resuscitation. He had been shot in the chest in a restaurant car park. After that, he was able to run 19 m to the main street before collapsing. On admission, he was semiconscious, pale and com- plained of shortness of breath. Blood pressure was < 60 mmHg with a pulse rate of < 120/min; clinical findings suggested a right-sided haemothorax. An entry wound was observed on the ventral chest just a few centimetres left to the midline at about the fourth rib. After intubation, ventilation and starting of uncross- matched blood transfusion, a chest X-ray showed shadowing of the right hemithorax (Fig. 1), as well as a bullet situated somewhere in the right chest. A tube-thoracostomy was performed and there was immediate drainage of 1.5 l of blood. Cardiorespiratory measurements further deteriorated and decision for immediate transfer to theatre was made. We choose a longitudinal sternotomy for access. As there was no sternotomy was available, we had to use an 0969-9546  c 2006 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.