Transcript Penetrating Trauma

Gunshot Wounds: Old and New
“A fear of weapons is a sign of retarded sexual
and emotional maturity”
Vocabulary 101
•Automatic
•Semi-Automatic
•Assault Rifle
•Cartridge
•Bullet
•Round
•Magazine
•Clip
USA Gun Deaths
58% suicides (17,000)
67% homicides (11,000)
Guns account for 0.7%
Accidental (1/2 hunting
1/2 “mishandling”) (total
about 800/yr)
Most weapons in crimes
illegally obtained
Year 2000 % of households with guns
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United States
Israel
Switzerland
Norway
Canada
Finland
France
48.0
92.3
90.0
32.0
29.1
23
22
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New Zealand
Austria
Belgium
Italy
Sweden
Northern I
Scotland
England
22
19.4
16.6
16.0
15.1
8.4
4.7
4.7
Wounding Potential
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Rules
 Energy cannot be
created or
destroyed
Consider
 Anatomy of impact
site
 Type of
weapon/ammo
 Penetration
Ammunition
 Cartridge case- seals
chamber against rear
escape of gases
 Primer- explodes on
compression
 Propellant-burns to produce
gases under pressure
 Magnum more pressure
 Bullet- Part of cartridge
which exits the muzzle
Ammunition
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Fully Jacketed
Soft Point
Wadcutter
Frangible
Expansion
Weight Retention
Penetration
Handguns
 Most confrontations occur
within 7 meters
 11% of assailants bullets hit
the intended target, while
25% of police bullets hit their
intended targets.
 Less range and less velocity
 Shot placement and bullet
characteristics dictate
effectiveness
 FBI Studies
 90% of Gun Related
Homicides
Submachine guns
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Example: H&K MP5
Pistol Cartridges
EFFECTIVE RANGE: 50m
Up to 800 rounds per
minute
 FEED: 15 or 30 round
magazine
Rifles
 Higher energy
 Easier to be
accurate
 Long Range - Up to
3 miles
Shotguns
 Shotguns are
capable of firing
pellets, larger metal
balls (buck-shot), or
slugs.
 These projectiles
are loaded into shell
with gunpowder
behind “wadding”
 00 Buck = 0.31 in
Range
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Direct contact
Close range
Energy Lost
Entry
Exit
Knockdown - .45
ACP (45 auto) =
1 lb dropped 11.4
feet.
Wound (Terminal) ballistics
 Weapon, Anatomy and bullet factors
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Tissue type- Most important Factor
Laceration “drilling effect”-Permanent cavity
Tissue stretch-Temporary cavity
Shock Waves at up to 1500m/s
People are not made of Ballistic Gelatin
Fackler - Army research lab - Occult damage-0.5
CM from wound edge
 125-230fps penetrate skin
Terminal ballistics
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Stability –Yaw, precession, nutation (tumble)
Fragmentation-more likely at higher velocities
Secondary projectiles
“Our findings indicate that every bullet's
path is a unique event” Military Medicine
Dec 2001, Korac
The Human Target
Anatomic location
Penetration
Bullet fragmentation
Retained Weight of
Projectile
“Knockdown”
CNS only reliable location
for immediate
incapacitation
GSW head
Groin GSW
Patient Management
Pre-hospital Information (often not reliable)
ABCDE - examine wounds (esp neck wounds)
Greater than 80% of those fatally wounded by a bullet die
within 30 minutes of injury Pope A, French G, Longnecker DE
SAVE THE STORY FOR THE JURY
Bleeding
Bleeding
Bleeding
Recent Research
Hemostatic Dressing
 64 combat uses
 25 chest, groin,
buttock, and
abdomen
 35 extremities
 4 neck or facial
 97% successful
Wedmore, The Journal of Trauma: Injury, Infection,
and Critical Care: March 2006 - Volume 60 - Issue 3
- pp 655-658
Tourniquet
Israeli Defensive Force Experience
91 cases over 4 year period
Most common indications for use
Mass casualties
Care under fire
Amputations
NO cases of death by uncontrolled hemorrhage seen
 How Long can it be left in place?
 Up to 2 hours warm ischemic time standard in orthopedic
surgery
 Every ED an EMS unit should have.
Ostman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia and
Reperfusion in Human Skeletal Muscle. Clin Orthop: 2004; 418:260-265
Klenerman L. Tourniquet Time—How Long? Hand. 1980; 12(3):231-4
Blood Components
• Component replacement should occur only in the
presence off active bleeding or if interventional procedures
are to be undertaken
• Ratio 1RBC:1Platelets:1 FFP
• Platelet concentrates (1pack/10kg) are given if platelet
count <50.
• FFP (12 ml/kg) is administered if PT or PTT are running
higher than 1.5 times control levels
• Cryo 1-1.5 packs/10kgs is given for fibrinogen levels <0.8
• Factor VII – No benefit
•
• J Trauma. 2006 Jul;61(1):181-4
Seaman, D. M. J., Park, G. R.;Trauma.org, resuscitation:
“Transfusion for Massive Blood Loss”.
•
Massoli, K. L.; Lecture:
“Blood Component Therapy and Massive Transfusion,”
Jan., 2003. Stene, J. K., Grande, C. M.:
Management
• Wound description - Only
what you see
• Small wounds = poss
extensive internal damage
• Missiles do not always travel
in straight lines
• Consider Intra-abdominal
injury
• Vascular injury-hematoma,
pulse deficit, bruit, pulsitile or
uncontrolled bleeding
• Beware multiple wounds
Penetrating abdominal trauma
 History:
 1800’s surgical dogma for nonoperative/supportive
care of abdominal GSW
 1881 President James A. Garfield shot in
abdomen. “Garfield’s death watch.”
 1890 Sir William McCormick, British chief army
surgeon “if a man undergoes surgery after being
shot, he dies, and lives if left in peace.”
 Continued standard of care through most of WWI
Britt, Rushing. “Penetrating Abdominal Trauma.” Current surgical therapy. 9
th
Ed. Pp 964-5. 2008
Penetrating abdominal trauma
 History continued
 WWI- higher M/M for non op pt’s.
 WWII, Korean war standard of care reversed
to mandatory laparotomy.
 Continued until 1960- Shaftan and Nance
endorse “selective conservatism” concern
re:negative lap rates
 Tulane 1973
Shaftan GW. Indicaton for operation in abdominal trauma. Am J Surg. 99:657, 1960.
Penetrating abdominal trauma
 History to now
 Evolution of DPL/CT/ FAST, increases non
operative evaluation/treatment in stable
pt’s.
 Laparoscopic options
Britt, Rushing. “Penetrating Abdominal
Trauma.” Current surgical therapy. 9th Ed.
Pp 964-5. 2008
Pearls of penetrating abdominal
trauma
 Most common injured intraabdominal
organ
 Small intestine
 Most common injured solid organ
 liver
Reviewing assessment of
abdominal penetrating trauma
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ABC’s
Controlled resuscitation
Secondary survey
Tertiary survey
 Mark all injury sites prior to Xray
 Hx of number of shots fired, type of
weapon, length of knife, sites of pain, etc
 Diagnostic planning
Indications for emergent
laparotomy
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Peritonitis
Hemodynamic instability
Evisceration
Blood from natural orifices
impaled object
High velocity missile injury
Operative goals/plan
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Stop the bleeding
Control contamination
Identify all injuries
Definitive repair of injuries vs damage
control
Selective Operative
Management
Hemodynamically stable, No diffuse abdominal tenderness
CT then OPERATIVE vs. EXPECTANT
1/3 have no significant injuries (Demetriades, Cornwell, et al, Arch Surg, 1997)
2/3 to back have no sign. injuries (Velmahos, Demetriades, et al, Am J Surg, 1997)
CT can demonstrate trajectory, relation to vital structures,
Site and size of solid organ injury, presence of pseudoaneurysm
<5% of pts managed nonoperatively will need subsequent laparotomy
<0.5% will have any associated complications from the delay
Muckart DJ, Abdool-Carrim AT, King B. Selective
conservative management of abdominal gunshot wounds:
a prospective study. Br J Surg 1990, 77(6):652-5.
111 patients with GSW to abdomen
Laparotomy decision based on physical examination alone
80% immediate laparotomy
8% negative lap
20% conservative management
None required delayed laparotomy
Demetriades D, Charalambides D, et al. Gunshot wound of
the abdomen: role of selective conservative management.
Br J Surg 1991, 78(2):220-2.
146 pts with GSW to abdomen
105 (72%) acute abdomen, immediate exploration
41 (28%) equivocal or minimal exam, observed
7 (17% of observed group) required laparotomy, no added
morbidity
Velmahos, Demetriades, et al. Selective Nonoperative
Management in 1,856 Patients with Abdominal Gunshot
Wounds. Ann Surg. 2001; 234(3):395-403.
8 year period at one trauma center
1856 patients seen with abdominal GSW
1405 anterior. 451 posterior.
792 managed nonoperatively
(34% anterior, 68% posterior).
Exclusion criteria:
peritonitis, hemodynamic instability, unreliable exam
Velmahos, Demetriades, et al. Selective Nonoperative
Management in 1,856 Patients with Abdominal Gunshot
Wounds. Ann Surg. 2001; 234(3):395-403.
4% progressed to delayed laparotomy
only 61% needed even this laparotomy
0.3% had complications related to delay of operation
(abscess, pneumonia, ileus)
Cost analysis:
routine laparotomy: 47% would have been unnecessary
3560 hospital days saved
$10 million saved
Santucci 2007, Renal Trauma
Outcome
Status
Stab (N=87)
GSW (N=52) P-value
Transfusion
Yes
14 (16%)
40 (77%)
No
73 (84%)
12 (23%)
0 (0%)
16 (31%)
87 (100%)
36 (69%)
9 (10%)
4 (8%)
78 (90%)
48 (92%)
Nephrectomy Yes
No
Delayed
Yes
Complication
No
<.0001
<.0001
0.767
Santucci 2007, Renal Trauma
 Expectant management is a reasonable
option for the treatment of renal stab wounds
 Approximately 50% of patients with LVGSW
will require GU-specific surgical intervention
 HVGSW mandated more aggressive
treatment
 A renal salvage rate of 88.5% (123/139) for
penetrating trauma was achieved with
selected exploration and an organ preserving
strategy for grades II-IV renal injury.
Selective Operative
Management
Benefit: Avoidance of Unnecessary Laparotomies
Analysis of 16 major studies, 8111 SW/GSW patients
1667 (21%) unnecessary laparotomies with 11% morbidity
(pneumonia, ileus, wound ifxn, SBO, incisional hernia)
Higher length of stay (5-10d vs 1-2d)
Much higher cost (up to $10,000 extra hosptial charges per patient)
Sequelae: Consequences of Missed Injuries
Analysis of 5 prospective studies, 728 patients
25 (3.4%) with delayed diagnosis of injuries
7 (28%) complications, no deaths
(wound ifxn, abscess, ARDS, pancreatic fistula)
UK algorithm: Penetrating Trauma
CXR, exam, FAST, local
exploration
Unstable, Peritonitis,
Evisceration, blood in NG
or rectal
Stable, no clear
perforated
viscous/organ/vasculature
Ex Lap
CT Abd/Pelvis
EAST Guideline 2010
 Peritonitis, Unstable – Ex Lap (I)
 MS changes/CNS injury – Ex Lap or
Immediate Imaging (I)
 Stable vitals, tangential GSW – no Ex Lap,
Imaging (II)
 Serial exams are reliable (II)
 CT for non op patients (II)
 Consider laparoscopy (II)
Summary
• Treat patient and
wound NOT the
weapon
• Reassess
• Describe wounds
simply
• Think - bullet path
QUESTIONS
Weapon Safety 101
For All You Gun Nuts
 All weapons are loaded
 Never point the muzzle at
anything you do not want
to destroy
 Finger OFF the trigger till
ready to fire
MYTHS
 Kinetic energy explains
tissue injury
 Entrance and exit can
be easily determined
 High velocity wounds all
need extensive
debridement
 Knockdown Power