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“ A fear of weapons is a sign of retarded sexual and emotional maturity ”

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)

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“ A fear of weapons is a sign of retarded sexual and emotional maturity ”

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  1. Gunshot Wounds: Old and New “A fear of weapons is a sign of retarded sexual and emotional maturity”

  2. Vocabulary 101 • Automatic • Semi-Automatic • Assault Rifle • Cartridge • Bullet • Round • Magazine • Clip

  3. 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

  4. United States48.0 Israel 92.3 Switzerland 90.0 Norway 32.0 Canada 29.1 Finland 23 France 22 New Zealand 22 Austria 19.4 Belgium 16.6 Italy 16.0 Sweden 15.1 Northern I 8.4 Scotland 4.7 England 4.7 Year 2000 % of households with guns

  5. Wounding Potential • Rules • Energy cannot be created or destroyed • Consider • Anatomy of impact site • Type of weapon/ammo • Penetration

  6. 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

  7. Ammunition • Fully Jacketed • Soft Point • Wadcutter • Frangible • Expansion • Weight Retention • Penetration

  8. 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

  9. Example: H&K MP5 Pistol Cartridges EFFECTIVE RANGE: 50m Up to 800 rounds per minute FEED: 15 or 30 round magazine Submachine guns

  10. Rifles • Higher energy • Easier to be accurate • Long Range - Up to 3 miles

  11. 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

  12. Range • Direct contact • Close range • Energy Lost • Entry • Exit • Knockdown - .45 ACP (45 auto) = 1 lb dropped 11.4 feet.

  13. Wound (Terminal) ballistics • Weapon, Anatomy and bullet factors • 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

  14. Terminal ballistics • 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

  15. The Human Target Anatomic location Penetration Bullet fragmentation Retained Weight of Projectile “Knockdown” CNS only reliable location for immediate incapacitation

  16. GSW head

  17. Groin GSW

  18. 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

  19. 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

  20. 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

  21. 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.:

  22. 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

  23. 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. 9th Ed. Pp 964-5. 2008

  24. 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.

  25. 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

  26. Pearls of penetrating abdominal trauma • Most common injured intraabdominal organ • Small intestine • Most common injured solid organ • liver

  27. Reviewing assessment of abdominal penetrating trauma • 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

  28. Indications for emergent laparotomy • Peritonitis • Hemodynamic instability • Evisceration • Blood from natural orifices • impaled object • High velocity missile injury

  29. Operative goals/plan • Stop the bleeding • Control contamination • Identify all injuries • Definitive repair of injuries vs damage control

  30. 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

  31. 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

  32. 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

  33. 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 center1856 patients seen with abdominal GSW1405 anterior. 451 posterior. 792 managed nonoperatively(34% anterior, 68% posterior). Exclusion criteria:peritonitis, hemodynamic instability, unreliableexam

  34. 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 laparotomyonly 61% needed even this laparotomy0.3% had complications related to delay of operation(abscess, pneumonia, ileus)Cost analysis:routine laparotomy: 47% would have been unnecessary3560 hospital days saved$10 million saved

  35. Santucci 2007, Renal Trauma

  36. 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.

  37. 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)

  38. UK algorithm: Penetrating Trauma

  39. 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)

  40. Summary • Treat patient and wound NOT the weapon • Reassess • Describe wounds simply • Think - bullet path

  41. QUESTIONS

  42. 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

  43. MYTHS • Kinetic energy explains tissue injury • Entrance and exit can be easily determined • High velocity wounds all need extensive debridement • Knockdown Power

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