Peacetime gunshot wounds

The article describes main principles of treatment of civilian gunshot wounds: rational organization of medical care to wounded at the prehospital stage, combination of diagnostic and medical process in specialized centers, early detection and eradication of menacing to life consequences of the wound, valuable intensive therapy at all stages of medical care and treatment, the shortest in time and full in volume specialized surgical care. Results of treatment of 507 patients with gunshot injuries of different localization in the clinic of military surgery for the last 15 years show that during this period the amount of such patients rose from 6.4% to 12.2% of all patients with different injuries, slight wounds taking place in 30.8%, of mean gravity--in 7.1%, grave--in 46.4%, critically grave--in 14.9%. Lethality made up 17.2%, incidence of complications--31.2%, duration of hospital treatment was 33 +/- 1.8 days.     

Low-velocity gunshot wounds to extremities

Several therapeutic modalities in the management of low-velocity gunshot wounds to extremities were investigated. Local excision of wound margins, irrigation, and primary or delayed primary closure without the use of the operating room or prophylactic antibiotics produced results which were comparable to those obtained with a more aggressive surgical protocol.     

Fatal cerebral gunshot wounds: factors influencing organ donation

Patients with clinical brain death following head injury are important potential cadaveric organ donors. We analyzed our series of cranial gunshot wounds with particular attention to the frequency and patterns of organ donation after fatal injuries. Sixty-six patients with gunshot wounds to the head, including 59 with intracranial involvement (43 male, average age 26 years) were seen during a 4-year period. Injuries were limited to the head in 50 of 59 patients. Overall mortality was 66 per cent. Predictors of mortality included Glasgow Coma Scale (GCS) of six or less (93%), self-inflicted gunshot wounds (75%), and computed tomography (CT) findings of bihemispheric injury (87%) or ventricular injury (82%). Of the 39 patients who died, 28 met standard criteria for brain death, and nine of these went on to organ procurement. Thirteen families refused donation, and six patients were not harvested for reasons including old age, pregnancy, suspicion of AIDS, coroner refusal, and failure to pursue consent. Principles essential to maximal organ retrieval include: 1) Recognition that patients suffering cerebral gunshot wounds represent potential organ donors and that certain factors are predictive of mortality; 2) Critical care/trauma team approach with standardized management and timely declaration of brain death; 3) Early search for family members and prompt notification of organ procurement agencies; 4) Sensitivity to cultural issues influencing donation; and 5) Programs to increase public awareness of organ donation.     

Clinical and therapeutic aspects of stab and gunshot wounds

In the last three years (1992-1995) 130 stab (114) and gunshot (16) wounds were observed at and admitted to the Emergency Surgical Department of Fatebenefratelli Hospital of Milan. We observed a high incidence of non-EEC patients (62%). Imaging devices (US and CT scan) and surgical minimally invasive procedures have reduced open surgery rate with a remarkable reduction in drawbacks and mortality.     

Emergency radiation study in thoracoabdominal gunshot wounds

The paper considers the main issues of a primary emergency radiology in thoracic and abdominal gunshot injury proceeding from some practical experience gained in examining and surgically treating 271 victims with this injury. It defines specific indications to examine either anatomic region and expediency of applying various radiation techniques and procedures. Recommendations are given on the optimum scope of radiology to solve different diagnostic problems. By and large, principles and policy of radiation study are defined in thoracic and abdominal gunshot injuries.     

Findings in gunshot wounds from tandem projectiles

Tandem projectiles are unusual events which can cause erroneous case interpretations if one is unfamiliar with them. This paper presents two such cases. The first case involved three .32 caliber bullets, two of which became lodged in a revolver barrel because of faulty ammunition. A third fired bullet subsequently pushed itself and the lodged bullets out of the barrel resulting in a single entrance wound with three bullets in the body. The second case involved a 20 gauge shotgun shell which apparently was inadvertently loaded into a 12 gauge shotgun. This resulted in an unusual entrance wound and unusual X-rays with fragments of the 20 gauge shotgun shell, as well as 12 gauge shotgun shell wadding, being removed from the same wound. The pertinent findings in such cases are discussed so that they may be correctly identified when they occur.     

Renal salvage of haemoglobin iron

Recycling of radioiron by renal tubular cells was studied in rats labelled by the i.v. injection of free 59Fe-Hb. Within 24 h, most of the renal radioactivity has been transferred from Hb to cellular ferritin and haemosiderin. Between day 1 and 14 of the study, urinary loss of radioactivity was less than 1% and most of the reduction in renal radioactivity represented transfer of renal iron into the circulation. An unexpected flexibility in the ability of rat kidney to recycle iron into the body has been found ranging from 13% in hypertransfused rats to 70% in bled animals. The high rate of renal iron transfer in bled animals was maintained under experimental conditions simulating chronic haemoglobinuria when most of the Hb removed by bleeding has been reinjected in the form of soluble Hb. Thus, epithelial cells in rat kidney as well as in the gut, appear to be able to transport iron with a much greater efficiency than in man, thereby contributing to the supply of iron for the rapid rates of growth and reproduction characteristic of this animal species.     

Primary closure of gunshot wounds caused by high-velocity rifles

Sixty gunshot injuries in 48 patients were treated in Mobile Surgical Hospital (30-bed capacity) of the Mountain and Commando Brigade in Hakkari, Türkiye, between May 1990 and May 1991. The David Sisk method was used for the classification of the injuries. Eleven type 1 injuries were treated conservatively, 39 type 2 and 10 type 3 injuries were treated by extensive debridement with suction drainage and primary closure. No infection was seen in type 1 injuries. The infection rate was 2.56% in type 2 and 20% in type 3 injuries. The following results were obtained: type 1 injuries must be treated by conservative measures; type 2 injuries must be treated by primary closure following extensive debridement and suction drainage; type 3 injuries can be treated by extensive debridement with suction drainage and primary closure.     

Bilateral knee gunshot wounds successfully treated with arthroscopic bullet retrieval: a case report

One unusual case of bilateral knee joint gunshot wounds caused by a low-velocity low-energy missile is presented. Arthroscopic retrieval of the bullets was performed resulting in recovery within 5 days.     

Determining anatomic injury with computed tomography in selected torso gunshot wounds

BACKGROUND: Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS: Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS: Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION: CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.     

A selective approach to the management of gunshot wounds to the back

PURPOSE: To study corneal changes after endocapsular phacoemulsification cataract extraction and intraocular lens (IOL) implantation with a 3.5 mm clear corneal sutureless incision or a 5.0 mm clear corneal incision with an absorbable suture. SETTING: Northwest Kansas Eye Clinic, Hays, Kansas, USA. METHODS: In a prospective study, 200 eyes were randomly distributed into two groups. Group A comprised 100 eyes that had a silicone IOL inserted through a 3.5 mm sutureless clear corneal incision. Group B comprised 100 eyes that had a 5.0 mm poly(methyl methacrylate) (PMMA) IOL inserted through a 5.0 mm clear corneal incision; one half of the closures used a single radial suture (Group B1), and the other half, an X suture (Group B2). Preoperatively, corneal topography and corneal endothelial cell counts were performed. Six to 8 months postoperatively, they were repeated and evaluated. Differential topography was used to determine the difference between the preoperative and postoperative corneas. During the final postoperative visit, IOL centration was evaluated. RESULTS: All closures produced only minimal changes in the corneal topographic indices. The postoperative corneas closely resembled the preoperative corneas. Polar K values showed a slight astigmatic shift in all groups. Group B2 was the only one to exhibit a with-the-rule shift. The change in endothelial cell counts was minimal and comparable in all three groups. CONCLUSION: The small amount of change in the corneal indices, especially in surface regularity, indicates that all corneas were relatively comparable and stable 6 to 9 months postoperatively regardless of the type of incision and closure method.     

A method of determining peritoneal penetration in gunshot wounds to the abdomen

BACKGROUND: It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA. METHODS: DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome. RESULTS: During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively. CONCLUSION: For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.     

Renal revascularization for kidney salvage or preservation

Quadriceps muscle and fibre cross-sectional areas (CSA), torque and neural activation were studied in seven healthy males during 6 months of weight training on alternate days with six series of eight unilateral leg extensions at 80% of one repetition maximum. After training, the quadriceps cross-sectional area increased by 18.8 +/- 7.2% (P < 0.001) and 19.3 +/- 6.7% (P < 0.001) in the distal and proximal regions respectively, and by 13.0 +/- 7.2% (P < 0.001) in the central region of the muscle. Hypertrophy was significantly different between and within the four constituents of the quadriceps. Biopsies of the vastus lateralis at mid-thigh did not show any increase in mean fibre cross-sectional area. Maximum isometric voluntary torque increased by 29.6 +/- 7.9%-21.1 +/- 8.6% (P < 0.01-0.05) between 100 degrees and 160 degrees of knee extension, but no change in the optimum angle (110 degrees-120 degrees) for torque generation was found. A 12.0 +/- 10.8% (P < 0.02) increase in torque per unit area together with a right shift in the IEMG-torque relation and no change in maximum IEMG were observed. Time to peak isometric torque decreased by 45.8% (P < 0.03) but no change in time to maximum IEMG was observed. In conclusion, strength training of the quadriceps results in a variable hypertrophy of its components without affecting its angle-torque relation. The increase in torque per unit area, in the absence of changes in IEMG, may indicate changes in muscle architecture. An increase in muscle-tendon stiffness may account for the decrease in time to peak torque.     

Is cervical spine imaging indicated in gunshot wounds to the cranium?

BACKGROUND, MATERIALS AND METHODS: Because there is no consensus regarding the necessity of imaging the cervical spine of patients who sustain a gunshot wound to the cranium, the cervical spinal radiographs of 53 consecutive patients with gunshot wounds to the cranium admitted to Hermann Hospital, a Level I trauma center, from January of 1993 to January of 1996, were reviewed. RESULTS: The cervical spine radiographs of all 53 patients were negative. CONCLUSIONS: Cervical spine injury is not associated with gunshot wound to the cranium. Therefore, patient management decisions/procedures, including endotracheal intubation, should not be delayed pending cervical spine imaging.     

The role of sigmoidoscopy in the management of gunshot wounds to the buttocks

The charts of all patients (n = 70) admitted over 26 months after sustaining a gunshot wound to the buttocks were reviewed to assess the role of physical examination, routine radiologic studies, and sigmoidoscopy in the evaluation of these patients. There were 68 men and 2 women. Sixteen patients underwent sigmoidoscopy, which demonstrated a rectal injury in 7. Six of these patients had other abnormalities on either physical examination or plain pelvic radiographs that would have otherwise led to operation. There were no missed injuries and no morbidity in the remaining patients that were managed without sigmoidoscopy. Indications for sigmoidoscopy were gross blood on rectal examination in 2, bullet path with proximity to the rectum in 13, and persistent abdominal pain in 1. All patients with gross blood on rectal examination (n = 5) and blood at the urethral meatus (n = 2) had visceral injuries. One patient underwent celiotomy for an injury at 15 cm that was noted on sigmoidoscopy performed because the bullet trajectory was in proximity to the rectum. Sigmoidoscopy can be performed selectively in patients sustaining a gunshot wound to the buttocks when the proximity of the wound to the rectum is in doubt.