Pulmonary artery embolism by a metal fragment after a booby trap explosion in a combat patient injured in the armed conflict in East Ukraine: a case report and review of the literature

Abstract

Background: Pulmonary artery embolization due to projectile embolus is a rare complication in combat patients. Such embolization is rare for combat patients in the ongoing armed conflict, in East Ukraine since 2014.

Case presentation: We report a clinical case of a 34-year-old Caucasian combat patient who was injured after an explosion of a booby trap hand grenade. This soldier was diagnosed with severe abdominal and skeletal trauma: damage of the duodenum and transverse colon, internal bleeding due to inferior vena cava damage and fractures of both lower extremities. The patient was treated at a highly specialized surgical center within the "golden hour" time. Whole-body computed tomography scan was performed as a routine screening method for hemodynamically stable patients, at which we identified a projectile embolus due to the explosion of a booby trap hand grenade in the right midlobar pulmonary artery. Our patient had no clinical manifestation of pulmonary artery embolism. At follow-up, our patient was diagnosed with the following complications: multiple necrosis and perforations of the transverse colon leading to a fecal peritonitis; duodenum suture line leakage caused the formation of a duodenal fistula; postoperative wound infection. These complications required multiple secondary operations, and in accordance to the principles of damage-control tactics, the extraction of projectile-embolus was postponed. Open surgery retrieval of the metal fragment was successfully performed on the 80th day after injury. Our patient was discharged from the hospital on day 168th after injury.

Conclusions: Literature analysis shows a significant difference of clinical management for patient with projectile embolism in hybrid war settings as compared to previously described cases of combat and civil gunshot injuries. Damage control tactics and the concept of the "golden hour" are highly effective for those injured in a hybrid war. A whole-body computed tomography scan is an effective screening method for asymptomatic patients with projectile-embolism of the great vessels. The investigation of a greater cohort of combat patients with severe injuries and projectile-embolism should be performed in order to develop a better guideline for these patients and to save more lives.

Keywords: Armed conflict in Ukraine; Combat trauma; Damage control; Hybrid warfare; Projectile-embolus.

Fig. 1

Visualization of the metal fragment in the branch of the right mid-lobe pulmonary artery by spiral computed tomography (CT) scan on the third day after the injury. a A photograph of the two-dimensional reconstruction of the CT frontal view image with the projectile embolus in the right pulmonary artery (marked with an arrow); b A photograph of the two-dimensional reconstruction of the CT sagittal view image with the projectile embolus in the branch of the right mid-lobe pulmonary artery (marked with an arrow) (c) A photograph of three-dimensional reconstruction of the CT front view image showing the pulmonary artery with the projectile embolus (marked with an arrow); d A photograph of CT angiography illustrating the projectile embolus (marked with an arrow); e A photograph of three-dimensional reconstruction of the CT angiography illustrating projectile embolus (marked with an arrow); f A photograph of three-dimensional reconstruction of the CT angiography showing projectile embolus in the pulmonary artery (marked with an arrow)

Fig. 2

An intraoperative photograph of the transverse colon at the relaparotomy on the ninth day after the injury. A zone of the necrosis and perforation (marked with an arrow) at the site of previous suturing of the perforation wound of the transverse colon, fecal content of the bowel is surrounded by inflamed peritoneum

Fig. 3

A series of the X-ray images illustrating bones fractures of the lower extremities at follow-up of the upper third of the left shin (marked L) and the lower third of the right shin (marked R), metal osteosynthesis by rod external fixation devices. a An X-ray image of the upper third of the left shin and the lower third of the right shin on 102nd day after the injury; b An X-ray image of the upper third of the left shin and the lower third of the right shin on the 154th day after the injury; c, d An X-ray image of the upper third of the lower extremities on the 168th day after the injury, the external fixation devices removed

Fig. 4

Visualization of the projectile-embolus (marked with an arrow) in the right mid-lobe pulmonary artery on the 63rd day after the injury by chest X-ray (a) and by spiral computed tomography (b)

Fig. 5

An intraoperative photograph of the thoracotomy at removal of projectile-embolus from the right mid-lobe pulmonary artery. a The projectile embolus is visualized as a yellowish quadrat-shaped body (marked with an arrow) in the lumen of pulmonary artery. The medium-lobe pulmonary vein is fixed by a yellow traction suture; the trunk of the right pulmonary artery is fixed by the white traction suture; the right mid-lobe pulmonary artery is fixed by a red traction suture; thrombosed branch of the right mid-lobe artery is fixed by a dark traction suture. Side (b) and front (c) view of the metal projectile embolus after its removal

Fig. 6

The overall look of the patient with the postoperative and post-injury scars before discharge from hospital (168th day after the injury). Anterior lateral (a) and front (b) view of the patient in the standing position