It always must be ascertained that the path from the entrance wound is consistent with the bullet's current location, because a bullet may have reached its present location by embolization. Arterial and venous embolization of bullets and shotgun pellets, as well as bullet movement within the subarachnoid space in the head and spine, have been reported. It is generally accepted that a missile freely floating within a cardiac chamber should be removed to prevent embolization. 28 Missiles clearly embedded in chamber walls are relatively safe.28 Missile size does not seem to be especially important, as all sizes can produce morbidity after embolization. Two-dimensional echocardiography is useful in determining whether a missile is embedded in a chamber wall. 28 CT (particularly high-speed CT) and magnetic resonance imaging for nonmagnetic missiles also have a role. On chest radiographs, blurring of the margins of a pericardiac missile or fragment is a reason to suspect that the missile is in or next to the heart.25
Whenever a bullet is not found on radiographs of the body part predicted based on the entrance wound, the bullet's location is not known, and there is no exit wound, additional radiographs or fluoroscopy to find the bullet are mandatory. Immediately before surgery for missile removal, repeat radiographic confirmation of the exact location of the missile is usually indicated.
Interventional radiologic techniques are useful in bullet removal, including the removal of intravascular and intrarenal bullets. Significant deformation of an intravascular bullet is a relative contraindication to retrieval using a transarterial catheter because of potential damage to the intima. Arthroscopy sometimes can be used for removing bullets from joints, especially the knee.
Most bullets follow straight paths through the body, but sometimes, even in the absence of embolization, a bullet, particularly a handgun bullet, will not. It may ricochet off body structures, especially bone, or may follow fascial or tissue planes. Bullets traveling less than 1100 ft/s (335 m/s) are the ones most likely to be deflected by anatomic structures or to follow tissue planes. Bullet shape also influences the tendency to be deflected.
Far more common than bullet displacement by embolization from where it came to rest in the body at the end of its path is bullet movement due to the effect of gravity on a bullet that ends up free in the pleural space or peritoneal cavity.
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