“a fear of weapons is a sign of retarded sexual and emotional maturity” gunshot wounds: old and...
TRANSCRIPT
““A fear of weapons is a sign of retarded sexual A fear of weapons is a sign of retarded sexual and emotional maturity”and emotional maturity”
““A fear of weapons is a sign of retarded sexual A fear of weapons is a sign of retarded sexual and emotional maturity”and emotional maturity”
Gunshot Wounds: Old and New
Vocabulary 101Vocabulary 101Vocabulary 101Vocabulary 101
•AutomaticAutomatic
•Semi-AutomaticSemi-Automatic
•Assault RifleAssault Rifle
•CartridgeCartridge
•BulletBullet
•RoundRound
•MagazineMagazine
•ClipClip
USA Gun DeathsUSA Gun DeathsUSA Gun DeathsUSA Gun Deaths
58% suicides (17,000)58% suicides (17,000)
67% homicides (11,000)67% homicides (11,000)
Guns account for 0.7% Guns account for 0.7% Accidental (1/2 hunting Accidental (1/2 hunting 1/2 “mishandling”) (total 1/2 “mishandling”) (total about 800/yr)about 800/yr)
Most weapons in crimes Most weapons in crimes illegally obtainedillegally obtained
58% suicides (17,000)58% suicides (17,000)
67% homicides (11,000)67% homicides (11,000)
Guns account for 0.7% Guns account for 0.7% Accidental (1/2 hunting Accidental (1/2 hunting 1/2 “mishandling”) (total 1/2 “mishandling”) (total about 800/yr)about 800/yr)
Most weapons in crimes Most weapons in crimes illegally obtainedillegally obtained
Year 2000 % of households with gunsYear 2000 % of households with gunsYear 2000 % of households with gunsYear 2000 % of households with guns
United StatesUnited States 48.048.0 IsraelIsrael 92.392.3 SwitzerlandSwitzerland
90.090.0 NorwayNorway 32.032.0 CanadaCanada 29.129.1 FinlandFinland 2323 FranceFrance 22 22
United StatesUnited States 48.048.0 IsraelIsrael 92.392.3 SwitzerlandSwitzerland
90.090.0 NorwayNorway 32.032.0 CanadaCanada 29.129.1 FinlandFinland 2323 FranceFrance 22 22
New ZealandNew Zealand 2222 AustriaAustria 19.419.4 BelgiumBelgium 16.616.6 ItalyItaly 16.016.0 SwedenSweden 15.115.1 Northern INorthern I 8.48.4 ScotlandScotland 4.74.7 England England 4.74.7
New ZealandNew Zealand 2222 AustriaAustria 19.419.4 BelgiumBelgium 16.616.6 ItalyItaly 16.016.0 SwedenSweden 15.115.1 Northern INorthern I 8.48.4 ScotlandScotland 4.74.7 England England 4.74.7
Wounding PotentialWounding PotentialWounding PotentialWounding Potential
RulesRules Energy cannot be Energy cannot be
created or created or destroyeddestroyed
ConsiderConsider Anatomy of impact Anatomy of impact
sitesite Type of Type of
weapon/ammoweapon/ammo PenetrationPenetration
RulesRules Energy cannot be Energy cannot be
created or created or destroyeddestroyed
ConsiderConsider Anatomy of impact Anatomy of impact
sitesite Type of Type of
weapon/ammoweapon/ammo PenetrationPenetration
AmmunitionAmmunitionAmmunitionAmmunition
Cartridge case-Cartridge case- seals seals chamber against rear chamber against rear escape of gasesescape of gases
PrimerPrimer- explodes on - explodes on compressioncompression
PropellantPropellant-burns to produce -burns to produce gases under pressure gases under pressure
MagnumMagnum more pressure more pressure Bullet-Bullet- Part of cartridge Part of cartridge
which exits the muzzlewhich exits the muzzle
Cartridge case-Cartridge case- seals seals chamber against rear chamber against rear escape of gasesescape of gases
PrimerPrimer- explodes on - explodes on compressioncompression
PropellantPropellant-burns to produce -burns to produce gases under pressure gases under pressure
MagnumMagnum more pressure more pressure Bullet-Bullet- Part of cartridge Part of cartridge
which exits the muzzlewhich exits the muzzle
AmmunitionAmmunitionAmmunitionAmmunition
Fully JacketedFully Jacketed Soft PointSoft Point WadcutterWadcutter FrangibleFrangible ExpansionExpansion Weight RetentionWeight Retention PenetrationPenetration
Fully JacketedFully Jacketed Soft PointSoft Point WadcutterWadcutter FrangibleFrangible ExpansionExpansion Weight RetentionWeight Retention PenetrationPenetration
HandgunsHandgunsHandgunsHandguns Most confrontations occur Most confrontations occur
within 7 meterswithin 7 meters 11% of assailants bullets hit 11% of assailants bullets hit
the intended target, while the intended target, while 25% of police bullets hit their 25% of police bullets hit their intended targets.intended targets.
Less range and less velocityLess range and less velocity Shot placement and bullet Shot placement and bullet
characteristics dictate characteristics dictate effectivenesseffectiveness
FBI StudiesFBI Studies 90% of Gun Related 90% of Gun Related
HomicidesHomicides
Most confrontations occur Most confrontations occur within 7 meterswithin 7 meters
11% of assailants bullets hit 11% of assailants bullets hit the intended target, while the intended target, while 25% of police bullets hit their 25% of police bullets hit their intended targets.intended targets.
Less range and less velocityLess range and less velocity Shot placement and bullet Shot placement and bullet
characteristics dictate characteristics dictate effectivenesseffectiveness
FBI StudiesFBI Studies 90% of Gun Related 90% of Gun Related
HomicidesHomicides
Example: H&K MP5 Example: H&K MP5 Pistol Cartridges Pistol Cartridges EFFECTIVE RANGE: 50m EFFECTIVE RANGE: 50m Up to 800 rounds per Up to 800 rounds per
minute minute FEED: 15 or 30 round FEED: 15 or 30 round
magazine magazine
Example: H&K MP5 Example: H&K MP5 Pistol Cartridges Pistol Cartridges EFFECTIVE RANGE: 50m EFFECTIVE RANGE: 50m Up to 800 rounds per Up to 800 rounds per
minute minute FEED: 15 or 30 round FEED: 15 or 30 round
magazine magazine
Submachine gunsSubmachine gunsSubmachine gunsSubmachine guns
RiflesRiflesRiflesRifles
Higher energyHigher energy Easier to be Easier to be
accurateaccurate Long Range - Up to Long Range - Up to
3 miles 3 miles
Higher energyHigher energy Easier to be Easier to be
accurateaccurate Long Range - Up to Long Range - Up to
3 miles 3 miles
ShotgunsShotgunsShotgunsShotguns
Shotguns are capable Shotguns are capable of firing pellets, larger of firing pellets, larger metal balls (buck-metal balls (buck-shot), or slugs. shot), or slugs.
These projectiles are These projectiles are loaded into shell with loaded into shell with gunpowder behind gunpowder behind “wadding”“wadding”
00 Buck = 0.31 in00 Buck = 0.31 in
Shotguns are capable Shotguns are capable of firing pellets, larger of firing pellets, larger metal balls (buck-metal balls (buck-shot), or slugs. shot), or slugs.
These projectiles are These projectiles are loaded into shell with loaded into shell with gunpowder behind gunpowder behind “wadding”“wadding”
00 Buck = 0.31 in00 Buck = 0.31 in
RangeRangeRangeRange
Direct contact Direct contact Close rangeClose range Energy LostEnergy Lost Entry Entry ExitExit Knockdown - Knockdown - .45 .45
ACP (45 auto) = 1 ACP (45 auto) = 1 lb dropped 11.4 lb dropped 11.4 feet. feet.
Direct contact Direct contact Close rangeClose range Energy LostEnergy Lost Entry Entry ExitExit Knockdown - Knockdown - .45 .45
ACP (45 auto) = 1 ACP (45 auto) = 1 lb dropped 11.4 lb dropped 11.4 feet. feet.
Wound (Terminal) ballistics Wound (Terminal) ballistics Wound (Terminal) ballistics Wound (Terminal) ballistics Weapon, Anatomy and bullet factorsWeapon, Anatomy and bullet factors
Tissue type- Tissue type- Most important FactorMost important Factor Laceration Laceration “drilling effect”-“drilling effect”-Permanent cavityPermanent cavity Tissue Tissue stretchstretch--Temporary cavityTemporary cavity Shock Waves at up to 1500m/s Shock Waves at up to 1500m/s People are not made of Ballistic GelatinPeople are not made of Ballistic Gelatin Fackler - Army research lab - Occult damage-0.5 Fackler - Army research lab - Occult damage-0.5
CM from wound edgeCM from wound edge 125-230fps penetrate skin125-230fps penetrate skin
Weapon, Anatomy and bullet factorsWeapon, Anatomy and bullet factors Tissue type- Tissue type- Most important FactorMost important Factor Laceration Laceration “drilling effect”-“drilling effect”-Permanent cavityPermanent cavity Tissue Tissue stretchstretch--Temporary cavityTemporary cavity Shock Waves at up to 1500m/s Shock Waves at up to 1500m/s People are not made of Ballistic GelatinPeople are not made of Ballistic Gelatin Fackler - Army research lab - Occult damage-0.5 Fackler - Army research lab - Occult damage-0.5
CM from wound edgeCM from wound edge 125-230fps penetrate skin125-230fps penetrate skin
Terminal ballisticsTerminal ballisticsTerminal ballisticsTerminal ballistics Stability –Yaw, precession, nutation (tumble)Stability –Yaw, precession, nutation (tumble) Fragmentation-more likely at higher velocities Fragmentation-more likely at higher velocities Secondary projectilesSecondary projectiles ““Our findings indicate that every bullet's Our findings indicate that every bullet's
path is a unique eventpath is a unique event”” Military Medicine Military Medicine Dec 2001, Korac Dec 2001, Korac
Stability –Yaw, precession, nutation (tumble)Stability –Yaw, precession, nutation (tumble) Fragmentation-more likely at higher velocities Fragmentation-more likely at higher velocities Secondary projectilesSecondary projectiles ““Our findings indicate that every bullet's Our findings indicate that every bullet's
path is a unique eventpath is a unique event”” Military Medicine Military Medicine Dec 2001, Korac Dec 2001, Korac
The Human TargetThe Human TargetThe Human TargetThe Human Target
Anatomic locationAnatomic locationPenetrationPenetrationBullet fragmentationBullet fragmentationRetained Weight of Retained Weight of
ProjectileProjectile““Knockdown”Knockdown”CNS only reliable location CNS only reliable location
for immediate for immediate incapacitationincapacitation
Anatomic locationAnatomic locationPenetrationPenetrationBullet fragmentationBullet fragmentationRetained Weight of Retained Weight of
ProjectileProjectile““Knockdown”Knockdown”CNS only reliable location CNS only reliable location
for immediate for immediate incapacitationincapacitation
GSW headGSW headGSW headGSW head
Groin GSWGroin GSWGroin GSWGroin GSW
Patient ManagementPatient ManagementPatient ManagementPatient ManagementPre-hospital Information (often not reliable)Pre-hospital Information (often not reliable)
ABCDE - examine wounds (esp neck wounds)ABCDE - examine wounds (esp neck wounds)Greater than 80% of those fatally wounded by a bullet die Greater than 80% of those fatally wounded by a bullet die within 30 minutes of injury within 30 minutes of injury Pope A, French G, Longnecker DEPope A, French G, Longnecker DE
SAVE THE STORY FOR THE JURYSAVE THE STORY FOR THE JURY
BleedingBleeding
BleedingBleeding
BleedingBleeding
Recent ResearchRecent Research
Hemostatic DressingHemostatic DressingHemostatic DressingHemostatic Dressing
64 combat uses64 combat uses 25 chest, groin, 25 chest, groin,
buttock, and buttock, and abdomen abdomen
35 extremities35 extremities 4 neck or facial4 neck or facial 97% successful97% successful
64 combat uses64 combat uses 25 chest, groin, 25 chest, groin,
buttock, and buttock, and abdomen abdomen
35 extremities35 extremities 4 neck or facial4 neck or facial 97% successful97% successful
Wedmore, The Journal of Trauma: Injury, Infection, and Critical Care: March 2006 - Volume 60 - Issue 3 - pp 655-658
TourniquetTourniquetTourniquetTourniquetIsraeli Defensive Force ExperienceIsraeli Defensive Force Experience91 cases over 4 year period91 cases over 4 year periodMost common indications for useMost common indications for use
Mass casualtiesMass casualtiesCare under fireCare under fireAmputationsAmputations
NO cases of death by uncontrolled hemorrhage seenNO cases of death by uncontrolled hemorrhage seen How Long can it be left in place?How Long can it be left in place?
Up to 2 hours warm ischemic time standard in orthopedic surgeryUp to 2 hours warm ischemic time standard in orthopedic surgery Every ED an EMS unit should have.Every ED an EMS unit should have.
Ostman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andOstman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andReperfusion in Human Skeletal Muscle. Reperfusion in Human Skeletal Muscle. Clin OrthopClin Orthop: 2004; 418:260-265: 2004; 418:260-265
Klenerman L. Tourniquet Time—How Long? Klenerman L. Tourniquet Time—How Long? HandHand. 1980; 12(3):231-4. 1980; 12(3):231-4
Israeli Defensive Force ExperienceIsraeli Defensive Force Experience91 cases over 4 year period91 cases over 4 year periodMost common indications for useMost common indications for use
Mass casualtiesMass casualtiesCare under fireCare under fireAmputationsAmputations
NO cases of death by uncontrolled hemorrhage seenNO cases of death by uncontrolled hemorrhage seen How Long can it be left in place?How Long can it be left in place?
Up to 2 hours warm ischemic time standard in orthopedic surgeryUp to 2 hours warm ischemic time standard in orthopedic surgery Every ED an EMS unit should have.Every ED an EMS unit should have.
Ostman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andOstman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andReperfusion in Human Skeletal Muscle. Reperfusion in Human Skeletal Muscle. Clin OrthopClin Orthop: 2004; 418:260-265: 2004; 418:260-265
Klenerman L. Tourniquet Time—How Long? Klenerman L. Tourniquet Time—How Long? HandHand. 1980; 12(3):231-4. 1980; 12(3):231-4
Blood ComponentsBlood 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 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.:
• 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 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.:
ManagementManagementManagementManagement
• 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
• 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 traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma
History:History: 18001800’’s surgical dogma for nonoperative/supportive s surgical dogma for nonoperative/supportive
care of abdominal GSWcare of abdominal GSW 1881 President James A. Garfield shot in 1881 President James A. Garfield shot in
abdomen. abdomen. ““GarfieldGarfield’’s death watch.s death watch.”” 1890 Sir William McCormick, British chief army 1890 Sir William McCormick, British chief army
surgeon surgeon ““if a man undergoes surgery after being if a man undergoes surgery after being shot, he dies, and lives if left in peace.shot, he dies, and lives if left in peace.””
Continued standard of care through most of WWIContinued standard of care through most of WWI
History:History: 18001800’’s surgical dogma for nonoperative/supportive s surgical dogma for nonoperative/supportive
care of abdominal GSWcare of abdominal GSW 1881 President James A. Garfield shot in 1881 President James A. Garfield shot in
abdomen. abdomen. ““GarfieldGarfield’’s death watch.s death watch.”” 1890 Sir William McCormick, British chief army 1890 Sir William McCormick, British chief army
surgeon surgeon ““if a man undergoes surgery after being if a man undergoes surgery after being shot, he dies, and lives if left in peace.shot, he dies, and lives if left in peace.””
Continued standard of care through most of WWIContinued standard of care through most of WWIBritt, Rushing. “Penetrating Abdominal Trauma.” Current surgical therapy. 9
th Ed. Pp 964-5. 2008
Penetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma History continuedHistory continued
WWI- higher M/M for non op ptWWI- higher M/M for non op pt’’s.s. WWII, Korean war standard of care reversed WWII, Korean war standard of care reversed
to mandatory laparotomy.to mandatory laparotomy. Continued until 1960- Shaftan and Nance Continued until 1960- Shaftan and Nance
endorse endorse ““selective conservatismselective conservatism”” concern concern re:negative lap ratesre:negative lap rates
Tulane 1973Tulane 1973
History continuedHistory continued WWI- higher M/M for non op ptWWI- higher M/M for non op pt’’s.s. WWII, Korean war standard of care reversed WWII, Korean war standard of care reversed
to mandatory laparotomy.to mandatory laparotomy. Continued until 1960- Shaftan and Nance Continued until 1960- Shaftan and Nance
endorse endorse ““selective conservatismselective conservatism”” concern concern re:negative lap ratesre:negative lap rates
Tulane 1973Tulane 1973
Shaftan GW. Indicaton for operation in abdominal trauma. Am J Surg. 99:657, 1960.
Penetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma
History to nowHistory to now Evolution of DPL/CT/ FAST, increases non Evolution of DPL/CT/ FAST, increases non
operative evaluation/treatment in stable operative evaluation/treatment in stable ptpt’’s.s.
Laparoscopic optionsLaparoscopic options
History to nowHistory to now Evolution of DPL/CT/ FAST, increases non Evolution of DPL/CT/ FAST, increases non
operative evaluation/treatment in stable operative evaluation/treatment in stable ptpt’’s.s.
Laparoscopic optionsLaparoscopic options
Britt, Rushing. “Penetrating Abdominal Trauma.”
Current surgical therapy. 9th Ed. Pp 964-5. 2008
Pearls of penetrating abdominal Pearls of penetrating abdominal traumatrauma
Pearls of penetrating abdominal Pearls of penetrating abdominal traumatrauma
Most common injured intraabdominal Most common injured intraabdominal organorgan Small intestineSmall intestine
Most common injured solid organMost common injured solid organ liverliver
Most common injured intraabdominal Most common injured intraabdominal organorgan Small intestineSmall intestine
Most common injured solid organMost common injured solid organ liverliver
Reviewing assessment of Reviewing assessment of abdominal penetrating traumaabdominal penetrating trauma
Reviewing assessment of Reviewing assessment of abdominal penetrating traumaabdominal penetrating trauma
ABCABC’’ss Controlled resuscitationControlled resuscitation Secondary surveySecondary survey Tertiary surveyTertiary survey
Mark all injury sites prior to XrayMark all injury sites prior to Xray Hx of number of shots fired, type of weapon, Hx of number of shots fired, type of weapon,
length of knife, sites of pain, etclength of knife, sites of pain, etc Diagnostic planningDiagnostic planning
ABCABC’’ss Controlled resuscitationControlled resuscitation Secondary surveySecondary survey Tertiary surveyTertiary survey
Mark all injury sites prior to XrayMark all injury sites prior to Xray Hx of number of shots fired, type of weapon, Hx of number of shots fired, type of weapon,
length of knife, sites of pain, etclength of knife, sites of pain, etc Diagnostic planningDiagnostic planning
Indications for emergent Indications for emergent laparotomylaparotomy
Indications for emergent Indications for emergent laparotomylaparotomy
PeritonitisPeritonitis Hemodynamic instabilityHemodynamic instability EviscerationEvisceration Blood from natural orificesBlood from natural orifices impaled objectimpaled object High velocity missile injuryHigh velocity missile injury
PeritonitisPeritonitis Hemodynamic instabilityHemodynamic instability EviscerationEvisceration Blood from natural orificesBlood from natural orifices impaled objectimpaled object High velocity missile injuryHigh velocity missile injury
Operative goals/planOperative goals/planOperative goals/planOperative goals/plan
Stop the bleedingStop the bleeding Control contaminationControl contamination Identify all injuriesIdentify all injuries Definitive repair of injuries vs damage Definitive repair of injuries vs damage
controlcontrol
Stop the bleedingStop the bleeding Control contaminationControl contamination Identify all injuriesIdentify all injuries Definitive repair of injuries vs damage Definitive repair of injuries vs damage
controlcontrol
Hemodynamically stable, No diffuse abdominal tendernessHemodynamically stable, No diffuse abdominal tenderness
CT then OPERATIVE vs. EXPECTANTCT then OPERATIVE vs. EXPECTANT
1/3 have no significant injuries 1/3 have no significant injuries (Demetriades, Cornwell, et al, Arch Surg, 1997)(Demetriades, Cornwell, et al, Arch Surg, 1997)
2/3 to back have no sign. injuries 2/3 to back have no sign. injuries (Velmahos, Demetriades, et al, Am J Surg, 1997)(Velmahos, Demetriades, et al, Am J Surg, 1997)
CT can demonstrate trajectory, relation to vital structures,CT can demonstrate trajectory, relation to vital structures,
Site and size of solid organ injury, presence of pseudoaneurysmSite and size of solid organ injury, presence of pseudoaneurysm
<5% of pts managed nonoperatively will need subsequent laparotomy<5% of pts managed nonoperatively will need subsequent laparotomy
<0.5% will have any associated complications from the delay<0.5% will have any associated complications from the delay
Selective Operative Selective Operative ManagementManagement
Selective Operative Selective Operative ManagementManagement
111 patients with GSW to abdomen111 patients with GSW to abdomen
Laparotomy decision based on physical examination aloneLaparotomy decision based on physical examination alone
80% immediate laparotomy80% immediate laparotomy
8% negative lap8% negative lap
20% conservative management20% conservative management
None required delayed laparotomyNone required delayed laparotomy
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.
146 pts with GSW to abdomen146 pts with GSW to abdomen
105 (72%) acute abdomen, immediate exploration105 (72%) acute abdomen, immediate exploration
41 (28%) equivocal or minimal exam, observed41 (28%) equivocal or minimal exam, observed
7 (17% of observed group) required laparotomy, no added 7 (17% of observed group) required laparotomy, no added morbiditymorbidity
Demetriades D, Charalambides D, et al. Gunshot wound of the abdomen: role of selective conservative management.
Br J Surg 1991, 78(2):220-2.
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 center8 year period at one trauma center
1856 patients seen with abdominal GSW1856 patients seen with abdominal GSW
1405 anterior. 451 posterior.1405 anterior. 451 posterior.
792 managed nonoperatively792 managed nonoperatively
(34% anterior, 68% posterior).(34% anterior, 68% posterior).
Exclusion criteria:Exclusion criteria:
peritonitis, hemodynamic instability, unreliableperitonitis, 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 laparotomy4% progressed to delayed laparotomy
only 61% needed even this laparotomyonly 61% needed even this laparotomy
0.3% had complications related to delay of operation0.3% had complications related to delay of operation
(abscess, pneumonia, ileus)(abscess, pneumonia, ileus)
Cost analysis:Cost analysis:
routine laparotomy: 47% would have been unnecessaryroutine laparotomy: 47% would have been unnecessary
3560 hospital days saved3560 hospital days saved
$10 million saved$10 million saved
Santucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaOutcome Status Stab (N=87) GSW (N=52) P-value
Transfusion Yes 14 (16%) 40 (77%) <.0001
No 73 (84%) 12 (23%)
Nephrectomy Yes 0 (0%) 16 (31%) <.0001
No 87 (100%) 36 (69%)
Delayed Complication
Yes 9 (10%) 4 (8%) 0.767
No 78 (90%) 48 (92%)
Santucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal Trauma
Expectant management is a reasonable Expectant management is a reasonable option for the treatment of renal stab woundsoption for the treatment of renal stab wounds
Approximately 50% of patients with LVGSW Approximately 50% of patients with LVGSW will require GU-specific surgical interventionwill require GU-specific surgical intervention
HVGSW mandated more aggressive HVGSW mandated more aggressive treatment treatment
A renal salvage rate of 88.5% (123/139) for A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with penetrating trauma was achieved with selected exploration and an organ preserving selected exploration and an organ preserving strategy for grades II-IV renal injury.strategy for grades II-IV renal injury.
Expectant management is a reasonable Expectant management is a reasonable option for the treatment of renal stab woundsoption for the treatment of renal stab wounds
Approximately 50% of patients with LVGSW Approximately 50% of patients with LVGSW will require GU-specific surgical interventionwill require GU-specific surgical intervention
HVGSW mandated more aggressive HVGSW mandated more aggressive treatment treatment
A renal salvage rate of 88.5% (123/139) for A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with penetrating trauma was achieved with selected exploration and an organ preserving selected exploration and an organ preserving strategy for grades II-IV renal injury.strategy for grades II-IV renal injury.
Benefit: Avoidance of Unnecessary LaparotomiesBenefit: Avoidance of Unnecessary Laparotomies
Analysis of 16 major studies, 8111 SW/GSW patientsAnalysis of 16 major studies, 8111 SW/GSW patients
1667 (21%) unnecessary laparotomies with 11% morbidity1667 (21%) unnecessary laparotomies with 11% morbidity
(pneumonia, ileus, wound ifxn, SBO, incisional hernia)(pneumonia, ileus, wound ifxn, SBO, incisional hernia)
Higher length of stay (5-10d vs 1-2d)Higher length of stay (5-10d vs 1-2d)
Much higher cost (up to $10,000 extra hosptial charges per patient)Much higher cost (up to $10,000 extra hosptial charges per patient)
Sequelae: Consequences of Missed InjuriesSequelae: Consequences of Missed Injuries
Analysis of 5 prospective studies, 728 patientsAnalysis of 5 prospective studies, 728 patients
25 (3.4%) with delayed diagnosis of injuries25 (3.4%) with delayed diagnosis of injuries
7 (28%) complications, no deaths7 (28%) complications, no deaths
(wound ifxn, abscess, ARDS, pancreatic fistula)(wound ifxn, abscess, ARDS, pancreatic fistula)
Selective Operative Selective Operative ManagementManagement
Selective Operative Selective Operative ManagementManagement
UK algorithm: Penetrating Trauma
EAST Guideline 2010EAST Guideline 2010EAST Guideline 2010EAST Guideline 2010
Peritonitis, Unstable – Ex Lap (I)Peritonitis, Unstable – Ex Lap (I) MS changes/CNS injury – Ex Lap or MS changes/CNS injury – Ex Lap or
Immediate Imaging (I)Immediate Imaging (I) Stable vitals, tangential GSW – no Ex Lap, Stable vitals, tangential GSW – no Ex Lap,
Imaging (II)Imaging (II) Serial exams are reliable (II)Serial exams are reliable (II) CT for non op patients (II)CT for non op patients (II) Consider laparoscopy (II)Consider laparoscopy (II)
Peritonitis, Unstable – Ex Lap (I)Peritonitis, Unstable – Ex Lap (I) MS changes/CNS injury – Ex Lap or MS changes/CNS injury – Ex Lap or
Immediate Imaging (I)Immediate Imaging (I) Stable vitals, tangential GSW – no Ex Lap, Stable vitals, tangential GSW – no Ex Lap,
Imaging (II)Imaging (II) Serial exams are reliable (II)Serial exams are reliable (II) CT for non op patients (II)CT for non op patients (II) Consider laparoscopy (II)Consider laparoscopy (II)
SummarySummarySummarySummary
• Treat patient and wound NOT the weapon
• Reassess • Describe wounds
simply• Think - bullet path
• Treat patient and wound NOT the weapon
• Reassess • Describe wounds
simply• Think - bullet path
QUESTIONSQUESTIONSQUESTIONSQUESTIONS
Weapon Safety 101Weapon Safety 101Weapon Safety 101Weapon Safety 101
For All You Gun NutsFor All You Gun NutsFor All You Gun NutsFor All You Gun Nuts All weapons are loadedAll weapons are loaded Never point the muzzle at Never point the muzzle at
anything you do not want anything you do not want to destroyto destroy
Finger OFF the trigger till Finger OFF the trigger till ready to fireready to fire
All weapons are loadedAll weapons are loaded Never point the muzzle at Never point the muzzle at
anything you do not want anything you do not want to destroyto destroy
Finger OFF the trigger till Finger OFF the trigger till ready to fireready to fire
MYTHSMYTHSMYTHSMYTHS
Kinetic energy explains Kinetic energy explains tissue injury tissue injury
Entrance and exit can Entrance and exit can be easily determinedbe easily determined
High velocity wounds all High velocity wounds all need extensive need extensive debridementdebridement
Knockdown PowerKnockdown Power
Kinetic energy explains Kinetic energy explains tissue injury tissue injury
Entrance and exit can Entrance and exit can be easily determinedbe easily determined
High velocity wounds all High velocity wounds all need extensive need extensive debridementdebridement
Knockdown PowerKnockdown Power