Safety of imaging exploding bullets with ultrasound

A Unique Emotional Surgery: Removal of Unexploded Ordnance in a Patient With Vascular Injury

Cases of embedded unexploded ordnance are extremely rare and pose a risk to bystanders and health providers. A patient arrived at the Role 2 medical facility in the Turkish army, whose left arm was amputated due to a terrorist attack and major hemorrhages had been halted by clamping of the left subclavian artery and vein. A piece of metal wire running from the lateral chest wall was detected as an unexploded ordnance piece and it was removed surgically. In these challenging cases, safety principles should be acknowledged. Highlighting the basic precautions is important for similar scenarios and increases awareness of the utmost importance.

Unexploded Ordnance Management

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.

An Impaled Potential Unexploded Device in the Civilian Trauma Setting: A Case Report and Review of the Literature

BACKGROUND

The management of patients with impaled unexploded devices is rare in the civilian setting. However, as the lines of the traditional battlefield are blurred by modern warfare and terrorist activity, emergency providers should be familiar with facility protocols, plans, and contact information of their local resources for unexploded devices.

CASE REPORT

A 44-year-old male sustained a close-proximity blast injury to his lower extremities while manipulating a mortar-type firework. He presented to the regional trauma center with an open, comminuted distal femur fracture and radiographic evidence of a potential explosive device in his thigh. His management was coordinated with the local Explosive Ordinance Disposal and the fire department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Explosive devices pose a grave threat when encountered. Familiarization with protocols to manage these patients can mitigate disaster. Emergency providers should expect and be prepared to coordinate care for these patients.

The radiographic analysis of a wounded patient questioned of having retained unexploded ordinance

We present the case of a polytrauma patient brought into a military medical treatment facility in Khandahar, Afghanistan, whom on radiographic evaluation was identified to have multiple retained internal radiodensities, some of which resembled projectiles, not immediately obvious as to type, thus by default necessitating the consideration for retained unexploded ordinance. The ensuing analysis ultimately successfully identified the origin of retained radiodensities as inert fragments from a USSR 50/60 steel cored bullet as opposed to unexploded ordinance.

Stratification of risk to the surgical team in removal of small arms ammunition implanted in the craniofacial region: case report

In cases of penetrating injury with implantation of small arms ammunition, it can often be difficult to tell the difference between simple ballistics and ballistics associated with unexploded ordnances (UXOs). In the operative environment, where highly flammable substances are often close to the surgical site, detonation of UXOs could have catastrophic consequences for both the patient and surgical team. There is a paucity of information in the literature regarding how to evaluate whether an implanted munition contains explosive material. This report describes a patient who presented during Operation Enduring Freedom with an implanted munition suspicious for a UXO and the subsequent workup organized by Explosive Ordnance Disposal (EOD) Company prior to surgical removal. Clinical risk factors for UXOs include assassination attempts and/or wartime settings. Specific radiological features suggestive of a UXO include projectile size greater than 7.62-mm caliber, alterations in density of the tip, as well as radiological evidence of a hollowed-out core. If an implanted UXO is suspected, risks to the surgical and anesthesia teams can be minimized by notifying the nearest military installation with EOD capabilities and following clinical practice guidelines set forth by the Joint Theater Trauma System.

Ultrasound detection of foreign bodies and procedure guidance

As emergency physicians become familiar with the use of ultrasonography, this safe procedure will likely become a standard technique having multiple uses in the emergency department. Ultrasonography assists in foreign body localization and retrieval and is potentially important in applications, such as reliable endotracheal tube placement, visualization of ingested medication, vascular access, and drainage of collected fluids.