With transection of distal posterior descending R. coronary artery and vein treated and having ruled out any other cardiac injury, we considered our further priorities to be:
1) Explore abdomen (mandatory). For the bullet to have entered the L. 7th ICS and injure the distal RCA on the diaghragmatic surface of the heart in the midline, it had to have passed through the diaphragm and through the upper abdomen en route.
2) Explore L. chest. We were there, and could easily be done through the sternotomy - although less than optimal as you cannot adequately get at hilum, descending aorta, or esophagus.
3) Explore R. chest. We were not sure this would be needed, but decided to make final decision after doing 1) and 2). With the sternotomy exposure we could see the R. lung moving nicely through the intact pleura, and there was no evidence on this inspection of pneumothorax.
Actually we looked in L. chest first with him still on bypass feeling that we might have to press on or manipulate the heart to get good exposure. There was a large hematoma in the inferolateral aspect of LLL. We may have been able to leave this to resolve, but I elected to remove the injured portion of the lung with a fair sized wedge resection using staplers. The hematoma may not have become as large had we not had to heparinize him for bypass. Then he was weaned from bypass and heparin reversed.
Extended midline incision down to umbilicus. As the linea alba was cut, just inferior to xyphoid, the bullet literally popped out. The spleen was badly fractured. Bullet had entered fundus of stomach posterolaterally and exited anteriorly, then had also caused a shattering injury of L. lobe of liver. We did a splenectomy, closed the two holes in the stomach, and resected the distal L. lobe of the liver. We did not explore R. chest given our visual findings through the sternal incision and where we found the bullet. He made a good recovery.
This case has been used as an oral board question (as I presented here) both for general and thoracic surgery by some friends whom I've told about it - the obvious point being to stress the importance of thinking about associated abdominal injury with penetrating (or blunt) injury low in the chest. We become accustomed to thinking of the position of the diaphragm as being as we see it on routine full inspiration chest films. The dome of the diaphragm can ride as high as T5 (I'm told - anyhow quite high) on full expiration.
Tom mentioned that the tube pericardiotomy as done may have been less than optimal - a good point. The people involved tried a needle tap first, didn't get an adequate responce, so did what they had to do. A technique I've used for chronic pericardial effusion which rapidly reaccumulates (such as malignant), is to enter the pericardium with a large needle, then thread in a soft catheter. This can be rigged to a stopcock, and fluid drained incrementally as necessary, until definitive treatment can be undertaken. I have not tried this in trauma cases, and certainly not in a cardiac chamber injury case, but it could be something to consider when one has to buy time.