Case Report: Penetrating Thoracic Trauma by A Gunshot Involving the Heart

Introduction

There are stringent laws regarding firearms in Nepal. However, illegal possession of firearms is not uncommon in rural part of this mountainous country. Self-suspension by hanging and consumption of agricultural poisons are the common methods of suicides in Nepal. Use of firearms for committing suicide is rare. We report a case of firearm related fatality from Nepal, where a flint-lock type muzzle loader smooth bore firearm was used to commit suicide and discuss the interpretation of firearm related wounds during a medicolegal examination. The victim in the present case was a schizophrenic patient, who had to discontinue his prescription medication due to coronavirus (COVID-19) related lockdown.

Case report

The dead body of 45-year-old male was brought for autopsy. The body was stiff at all the joints. The hands were clenched and the whole body smeared in blood. Post mortem lividity could not be appreciated. A rectangular contusion with muzzle imprint was noted in the front of the chest which measured 10 × 8 cm. An oval perforated lacerated wound (entry wound) having 1.8 cm diameter was present in the middle of the contusion [Figure 1]. The wound was charred, black in color with surrounding blackening of the skin. The perforated wound was 48 cm from the vertex in midline, 115 cm from the sole of the foot and 18 cm from the supra sternal notch. It was 17 cm from the right mid axillary line and 20 cm from the left mid axillary line. A linear slit-like laceration (exit wound) was present on the back in the left side which measured 0.5 × 0.2 cm and was located 25 cm from the vertex, 129 cm from the sole of the foot [Figure 1].

Figure 1.

A, An oval entry wound is present on the front of the chest. B, A linear, slit-like lacerated exit wound on the back.

On opening the chest, a perforating fracture was noted in the xiphoid process [Figure 2]. The heart was pulverized [Figure 3] with exsanguination of the blood into pericardial cavity. The clotted blood in the pericardial cavity weighed about 650 gm. When a probe was directed through the heart from the defect, it was noted that the entry point was located on the right side of the anterior interventricular septum and exited through the left ventricle [Figure 3]. The direction was right to left and below upwards. The left lung was completely collapsed and there was a penetrating injury noted at the upper lobe. The rest of the findings were unremarkable.

Figure 2.

A, A perforating fracture in the xiphoid process. B, Punctured laceration is seen in the posterior chest wall.

Figure 3.

A, Pulverized heart. B, A wooden probe passed through the defect showing the direction of the projectile.

As per the history provided by the victim’s brother, the deceased was an unmarried male. He was diagnosed with schizophrenia since adolescence for which he was on the prescription medicine Quetiapine. The medicine was not available at his rural pharmacy and due to the COVID-19 pandemic lockdown, he was unable to visit the tertiary hospital for his regular prescription. The medicine was therefore discontinued for 3 months prior to death. The victim consumed homemade arrack (a distilled alcoholic drink) regularly which they prepared at their home.

The crime scene photograph provided by the investigating officer showed a single barrel, smooth-bored firearm which was a flint lock type muzzle loader [Figure 4].

Figure 4. The firearm recovered from the scene of crime.

Discussion

Shotgun wounds vary in characteristics depending upon type, distance, position and the number of shots. On entering the body cavity, projectiles follow the tissue of least resistance.¹ A shotgun wound in the chest cannot point well towards the manner of death. However, contact shots are more likely to be suicidal than homicidal and are more fatal for single shot.²

The entry wound showed some muzzle imprint, signifying a contact shot. The expanding gases that enter the chest cavity cause a bulging out of the skin against the muzzle, resulting in an imprint often significantly larger than the actual diameter of the muzzle.³ While in hard contact wounds most of the soot is directed into the wound, with little soil of the surrounding skin, in this case the use of black powder in the muzzle loader may have accounted for the extensive blackening of the skin.³ In the present case as the projectile had exited from the body it could not be ascertained on the type and number of projectiles (pellets). Due to limited resources at the mortuary radiological examination was not done in the present case.

Shots to the heart are very common, with only the head being a more common target.⁴ Suicidal victims are aware of the lethality of gunshots to this vital organ and some victims even locate the cardiac impulse before taking the shot. Furthermore, suicidal fire is more likely to be directed right to left with homicidal direction commonly being left to right.⁵ There was complete destruction of the heart noted at autopsy which was due to the hydrodynamic pressure generated by the passage of the projectile through the heart that caused blowout of its walls.

The crime scene visit in cases of firearm related mortality is equally important in interpreting the manner of death. In suicides, the offending weapon is usually found at the scene of crime in contrast to homicides where the perpetrator usually carries away the weapon after committing the crime.

In contrast to stab wounds, gunshot cause more exsanguination of blood due to jagged tearing of myocardium. 60 ml to 200 ml of clotted blood is enough to cause death. Penetrating thoracic trauma as a result of gunshot injuries are associated with traumatic hemothorax, hemopneumothorax, or pneumothorax.⁶ If the penetrating injury involves the heart, the chances of survival are less than 1%,⁶ as seen in our case. There are increased number of suicides from Nepal reported during the COVID-19 pandemic.⁷ The patients with underlying psychiatric disorder could not get access to their prescription medication due to the lockdown as all the public transportation was halted and people were afraid to get out of home. Discontinuation of medication in schizophrenic patients has shown to exacerbate the syndrome.⁸ This might have been the underlying reason for suicide in the present case. The present case further highlights the social concern the pandemic has brought where patients are restricted of access to their health care needs due to lack of transport in the lockdown.

Conclusion

Firearm fatalities are medicolegal cases where the autopsy surgeon is required to determine the manner of death based upon the injuries present over the body. Meticulous examination of the wound not only gives clues about the entry and exit wounds but also the range of fire and the weapon used. The manner of death can also be interpretated from the position and characteristics of the wound. A crime scene visit is also mandated in firearm related fatalities which will further help to corroborate the findings.

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