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Hussein AM, Ali AA, Ahmed SA, Mohamud MFY, Ahmed MAM, Kizilay M. Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center. Sci Rep 2024; 14:13004. [PMID: 38844514 PMCID: PMC11156839 DOI: 10.1038/s41598-024-63686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/31/2024] [Indexed: 06/09/2024] Open
Abstract
Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.
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Affiliation(s)
- Abdinafic Mohamud Hussein
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia.
- Department of General Surgery, Benadir University, Mogadishu, Somalia.
| | - Abdijalil Abdullahi Ali
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Said Abdirahman Ahmed
- Department of Cardiology, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Mohamed Farah Yusuf Mohamud
- Department of Emergency Medicine, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Mohammed A M Ahmed
- Department of Pediatrics, Faculty of Medicine and Surgery, Mogadishu University, Mogadishu, Somalia
| | - Mehmet Kizilay
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
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Lunga Z, Laubscher M, Graham SM, Held M, Ferreira N, Magampa R, Maqungo S. Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1667-1674. [PMID: 38386124 PMCID: PMC10980626 DOI: 10.1007/s00590-024-03853-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.
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Affiliation(s)
- Zamalunga Lunga
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa.
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa.
| | - Maritz Laubscher
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Simon Matthew Graham
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Oxford Trauma and Emergency Care. Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, UK
| | - Michael Held
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Ramanare Magampa
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
- Division of Global Surgery, University of Cape Town, Cape Town, South Africa
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Ząbkowski T, Brzozowski R, Durma AD. Renal injuries in conflict zones: a 6-year study of traumatic cases in Afghanistan. Confl Health 2024; 18:6. [PMID: 38183150 PMCID: PMC10770980 DOI: 10.1186/s13031-023-00566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE During hostilities, gunshot wounds are the most common cause of penetrating injuries. In 8-10% of abdominal injuries kidneys are involved. The treatment method include surgical or conservative treatment (fluids + blood components). METHODS Of 1266 combat trauma cases treated during 6 to 14 rotation of the Polish Military Contingent in Afghanistan, we extracted a subgroup of 44 kidney injuries. Corelation of trauma mechanism, PATI score, treatment methods, and outcomes was evaluated. RESULTS Out of the 41 renal injuries, 20 considered left, 18 right, and 3 both kidneys. There were no statistical significancy in injury lateralization (p = 0.669), and no differences regarding side of a trauma and quantity of blood component used for the treatment (p = 0.246). Nephrectomy was performed on 17 patients (13 left vs. 4 right). A significant correlation between PATI score and the need for a nephrectomy (p = 0.027) was confirmed. Penetrating trauma recquired higher number of blood components comparing to blunt trauma (p < 0.001). The renal salvage rate was in study group was 61.36%. The overall survival (OS) rate was 90.25% - 4 patients died due to trauma. CONCLUSIONS The damage side does not result in a statistically significant increase in the need for blood transfusions or differences in the PATI score. The mechanism of trauma does, however, affect the number of blood components required for treatment, particularly in cases of penetrating trauma. With the introduction of proper treatment, the overall survival rate exceeds 90%, even when opting for conservative treatment.
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Affiliation(s)
- Tomasz Ząbkowski
- Department of Urology, Miliary Institute of Medicine - National Research Institute, Warsaw, Poland
| | - Robert Brzozowski
- Department of General and Oncological Surgery, 5th Military Clinical Hospital with Polyclinic, Cracov, Poland
| | - Adam Daniel Durma
- Department of Endocrinology and Radioisotope Therapy, Miliary Institute of Medicine - National Research Institute, Warsaw, Poland.
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Alsalkini M, Hanafi I, Omarain A, Ahmad S, Munder E, ArabHamo I, Saleh M. Patterns of War-Related Traumatic Brain Injuries and Predictors of Mortality Among Civilians During the Syrian Armed Conflict. Neurosurgery 2023:00006123-990000000-00976. [PMID: 38032180 DOI: 10.1227/neu.0000000000002772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES High-velocity weapons were used against unshielded civilians during the Syrian armed conflict, leading to a variety of combat-related traumatic brain injuries with high fatality and morbidity. Because of the lack of data in the literature about the management and outcomes of similar injuries, we aimed in this study to characterize shrapnel and gunshot injuries in this vulnerable group and to describe the association between the mechanisms, site, and type of injury and the outcomes. METHODS This was a single-center retrospective cohort study on new traumatic brain injuries in civilians who presented alive to the neurosurgery department at Damascus Hospital between 2014 and 2017. The analyzed data included the mechanism of injury and its type and site based on computed tomography scans. We also studied the neurological status at admission, the major interventions applied, and outcomes including mortality and neurological deficits at discharge. RESULTS Shrapnel and gunshot injuries more likely affected the frontal and parietal lobes, respectively. While shrapnel led to injuries in multiple body parts, gunshots led to localized but more severe injuries. Despite that, mortality rates were comparable between the two mechanisms. Injuries to the right parietal and right frontal lobes were more fatal with odds ratios of 2.61 (1.23-5.52) and 2.12 (1.00-4.50), respectively. Moreover, mortality was also linked to the radiological findings of loss of brain material with an odds ratio of 3.73 (1.42-9.81), intracerebral hemorrhage with an odds ratio of 3.60 (1.67-7.80), intraventricular hemorrhage with an odds ratio of 5.49 (1.68-17.95), and subdural hemorrhage with an odds ratio of 6.35 (2.29-17.66). CONCLUSION The unfortunate nature of the Syrian armed conflict, wherein civilians were targeted during their daily routine, seems to manifest a heightened propensity to affect the parietal lobes, potentially resulting in higher morbidity. Although shrapnel and gunshot injuries showed no significant difference in mortality rates, injuries involving loss of brain tissue and intracranial hemorrhage emerged as independent predictors of mortality.
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Affiliation(s)
| | - Ibrahem Hanafi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Ahmad Omarain
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Sulafa Ahmad
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Eskander Munder
- Faculty of Medicine, Syrian Private University, Damascus, Syria
| | - Iman ArabHamo
- Faculty of Medicine, Syrian Private University, Damascus, Syria
| | - Muhannad Saleh
- Division of Neurosurgery, Department of Surgery, Damascus Hospital, Damascus, Syria
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Ujvári B, Oláh Z, Molnár S, Háncs T, Várhelyi L, Szabó N, Bózsik A. Multi-stage management of a right hip gunshot injury; Case report. Trauma Case Rep 2023; 47:100881. [PMID: 37587922 PMCID: PMC10425711 DOI: 10.1016/j.tcr.2023.100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/18/2023] Open
Abstract
A 42-year-old hunter with no previous medical history suffered an accidental gunshot injury while hunting. Upon arrival at our Hospital, the following musculosceletal laesions were diagnosed during the primary survey: comminuted right trochanteric and femur neck fracture, femoral and sciatic nerve palsy. The immediate damage control surgery consisted of debridement, jet-lavage, PMMA-chain insertion and extrafocal fixation. Structural neural damage was disclosed. Primarily the skin wound was treated by delayed closure and later the healing was supported by Negative Pressure Wound Therapy. Six weeks after, the extrafocal fixation was removed and antibiotic spacer was inserted. Primary wound healing occurred without any sign of infection. Neurological recovery of the extremity took almost a year. Low grade infection were excluded by serial labs and culture samples. Finally the patient underwent total hip arthroplasty with excellent result.
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Affiliation(s)
- Béla Ujvári
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Zoltán Oláh
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Szabolcs Molnár
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
- University of Physical Education, Budapest, Hungary
| | - Tivadar Háncs
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Levente Várhelyi
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Noé Szabó
- Medical Student, Semmelweis University Medicine and Health Sciences, Budapest, Hungary
| | - Attila Bózsik
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
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Singh Y, Motilall S, Khulu BL, Jackson BS. The impact of colon injuries on the outcome of gunshot wounds to the abdomen. Langenbecks Arch Surg 2023; 408:328. [PMID: 37612518 PMCID: PMC10447282 DOI: 10.1007/s00423-023-03067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Factors predicting morbidity and mortality in patients with colon-related gunshot injuries and the management of these injuries are not always straightforward. This aimed to assess the impact of abdominal gunshot wounds with colonic injuries on patients' overall outcomes. METHODS This cross-sectional prospective observational study compared patients with colon injuries and without colon injuries. Data was collected from admission, theatre and postoperative care. Patients were recruited between 1 January 2020 and 20 October 2021. RESULTS Of 132 patients with abdominal gunshot injuries, 71 (54.0%) had colon injuries. The colon injury group had a higher incidence of laparotomy wound sepsis (p<0.0001), bullet exit wound infection (p<0.0001), tract necrotizing fasciitis (p<0.0001), relook laparotomies (p<0.0001) and a longer hospital stay (p<0.0001). Septicaemia (p=0.002) or anastomotic leak (p=0.041) was associated with a penetrating abdominal trauma index (PATI) ≥25. Most patients who developed tract necrotizing fasciitis did not have their tract debrided/ lavaged (p=0.004). The type of colon repair did not influence the length of hospital stay (p=0.688) or the development of a colon-related complication (p=0.578). Between 18 and 25 years (p<0.0001) and >2 organs injured (p=0.018) were associated with colon-related complications. Patients between 18 and 25 years were 4.748 times more likely to develop a colon-related complication (p=0.046). CONCLUSION Gunshot wounds to the abdomen with associated colonic injuries had a worse outcome with an increased risk of developing wound infections. There is no difference in the operative management of colonic injury. Patients between the ages of 18 and 25 years or >2 organs injured are more likely to develop a complication.
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Affiliation(s)
- Yonita Singh
- Department of Surgery, Tembisa Provincial Tertiary Hospital, University of Pretoria, Pretoria, 0007, South Africa.
| | - Sooraj Motilall
- Department of Surgery, Steve Biko Academic Hospital, University of Pretoria, Pretoria, 0007, South Africa
| | - Bongani L Khulu
- Department of Surgery, Tembisa Provincial Tertiary Hospital, University of Pretoria, Pretoria, 0007, South Africa
| | - Brandon S Jackson
- Department of Surgery, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, 0007, South Africa
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Vakil AU, Petryk NM, Du C, Howes B, Stinfort D, Serinelli S, Gitto L, Ramezani M, Beaman HT, Monroe MBB. In vitro and in vivo degradation correlations for polyurethane foams with tunable degradation rates. J Biomed Mater Res A 2023; 111:580-595. [PMID: 36752708 DOI: 10.1002/jbm.a.37504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/19/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
Polyurethane foams present a tunable biomaterial platform with potential for use in a range of regenerative medicine applications. Achieving a balance between scaffold degradation rates and tissue ingrowth is vital for successful wound healing, and significant in vivo testing is required to understand these processes. Vigorous in vitro testing can minimize the number of animals that are required to gather reliable data; however, it is difficult to accurately select in vitro degradation conditions that can effectively mimic in vivo results. To that end, we performed a comprehensive in vitro assessment of the degradation of porous shape memory polyurethane foams with tunable degradation rates using varying concentrations of hydrogen peroxide to identify the medium that closely mimics measured in vivo degradation rates. Material degradation was studied over 12 weeks in vitro in 1%, 2%, or 3% hydrogen peroxide and in vivo in subcutaneous pockets in Sprague Dawley rats. We found that the in vitro degradation conditions that best predicted in vivo degradation rates varied based on the number of mechanisms by which the polymer degraded and the polymer hydrophilicity. Namely, more hydrophilic materials that degrade by both hydrolysis and oxidation require lower concentrations of hydrogen peroxide (1%) to mimic in vivo rates, while more hydrophobic scaffolds that degrade by oxidation alone require higher concentrations of hydrogen peroxide (3%) to model in vivo degradation. This information can be used to rationally select in vitro degradation conditions that accurately identify in vivo degradation rates prior to characterization in an animal model.
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Affiliation(s)
- Anand Utpal Vakil
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Natalie Marie Petryk
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Changling Du
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Bryanna Howes
- Department of Chemistry, Le Moyne College, Syracuse, New York, USA
| | | | | | - Lorenzo Gitto
- SUNY Upstate Medical University, Syracuse, New York, USA
| | - Maryam Ramezani
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Henry T Beaman
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Mary Beth Browning Monroe
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
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Pourhajshokr N, Sadeggi MS, Ghobadi J, Khanghah AS, Ezzativand H. Successful removal of a bullet from the spinal canal of a GSW victim in the level of L5: Case report. Int J Surg Case Rep 2022; 101:107779. [DOI: 10.1016/j.ijscr.2022.107779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
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PECULIARITIES OF THE PROJECTILE PENETRATION DEPTH WHEN FIRED WITH “FORT 9R” AND “FORT 17R” PISTOLS WHILE USING DIFFERENT CLOTHING FABRIC. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-4-82-230-235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Biofluid Biomarkers in Traumatic Brain Injury: A Systematic Scoping Review. Neurocrit Care 2021; 35:559-572. [PMID: 33403583 DOI: 10.1007/s12028-020-01173-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
Emerging evidence suggests that biofluid-based biomarkers have diagnostic and prognostic potential in traumatic brain injuries (TBI). However, owing to the lack of a conceptual framework or comprehensive review, it is difficult to visualize the breadth of materials that might be available. We conducted a systematic scoping review to map and categorize the evidence regarding biofluid-based biochemical markers of TBI. A comprehensive search was undertaken in January 2019. Of 25,354 records identified through the literature search, 1036 original human studies were included. Five hundred forty biofluid biomarkers were extracted from included studies and classified into 19 distinct categories. Three categories of biomarkers including cytokines, coagulation tests, and nerve tissue proteins were investigated more than others and assessed in almost half of the studies (560, 515, and 502 from 1036 studies, respectively). S100 beta as the most common biomarker for TBI was tested in 21.2% of studies (220 articles). Cortisol was the only biomarker measured in blood, cerebrospinal fluid, urine, and saliva. The most common sampling time was at admission and within 24 h of injury. The included studies focused mainly on biomarkers from blood and central nervous system sources, the adult population, and severe and blunt injuries. The most common outcome measures used in studies were changes in biomarker concentration level, Glasgow coma scale, Glasgow outcome scale, brain computed tomography scan, and mortality rate. Biofluid biomarkers could be clinically helpful in the diagnosis and prognosis of TBI. However, there was no single definitive biomarker with accurate characteristics. The present categorization would be a road map to investigate the biomarkers of the brain injury cascade separately and detect the most representative biomarker of each category. Also, this comprehensive categorization could provide a guiding framework to design combined panels of multiple biomarkers.
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Yoon SY, Sul YH. Surgically Removed Intrapulmonary Shotgun Pellet without Traumatic Hemopneumothorax. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2020.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Burgos-Díez I, Zapata F, Chamorro-Sancho MJ, Ruano-Rando MJ, Ferrando-Gil JL, García-Ruiz C, Montalvo G, Ortega-Ojeda F. Comparison between computed tomography and silicone-casting methods to determine gunshot cavities in ballistic soap. Int J Legal Med 2020; 135:829-836. [PMID: 33190163 DOI: 10.1007/s00414-020-02464-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
Current methods used in terminal ballistics to determine the volume of temporary cavities created by projectiles in soft tissue simulants (such as ballistic soap) usually involve silicone-casting to obtain the cavity moulds. However, these methods have important drawbacks including their little sensitivity and precision, besides the fact that they are destructive. Imaging techniques such as computed tomography (CT) might not only overcome those limitations but also offer useful tools for digitally reporting the scientific results. This work accomplished the 3D digital reconstruction of the cavities created by different projectiles in ballistic soap blocks. This way, the total volume of the cavities, the projectile penetration depths, and other measurements were determined, rendering better capabilities when compared to the current silicone method. All these features were achieved through the CT analysis and 3D Slicer imaging software. In addition, it is worth mentioning that the method can preserve the evidence by digitally obtaining, signing, and storing the infographic videos displaying the 3D-reconstructed cavities. Graphical abstract.
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Affiliation(s)
- Irene Burgos-Díez
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering and University Institute of Research in Police Sciences (IUICP), University of Alcalá, Ctra. Madrid-Barcelona km 33.6, 28871, Alcalá de Henares (Madrid), Spain
| | - Félix Zapata
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering and University Institute of Research in Police Sciences (IUICP), University of Alcalá, Ctra. Madrid-Barcelona km 33.6, 28871, Alcalá de Henares (Madrid), Spain
| | | | - Manuel Jesús Ruano-Rando
- Ballistics and Tool marks Department, Criminalistics Service, Guardia Civil HQ, Guzmán el Bueno, 110, 28003, Madrid, Spain
| | - José Luis Ferrando-Gil
- Ballistics and Tool marks Department, Criminalistics Service, Guardia Civil HQ, Guzmán el Bueno, 110, 28003, Madrid, Spain
| | - Carmen García-Ruiz
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering and University Institute of Research in Police Sciences (IUICP), University of Alcalá, Ctra. Madrid-Barcelona km 33.6, 28871, Alcalá de Henares (Madrid), Spain
| | - Gemma Montalvo
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering and University Institute of Research in Police Sciences (IUICP), University of Alcalá, Ctra. Madrid-Barcelona km 33.6, 28871, Alcalá de Henares (Madrid), Spain
| | - Fernando Ortega-Ojeda
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering and University Institute of Research in Police Sciences (IUICP), University of Alcalá, Ctra. Madrid-Barcelona km 33.6, 28871, Alcalá de Henares (Madrid), Spain.
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Pazarci O, Kilinc S, Camurcu Y, Bulut O. Total hip arthroplasty after hip joint gunshot injury. J Orthop Surg (Hong Kong) 2020; 27:2309499019873113. [PMID: 31496364 DOI: 10.1177/2309499019873113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Gunshot injury of the hip joint was reported to constitute 2-17% of all extremity firearm injuries. However, there are few studies in the literature related to gunshot injuries of the hip joint. The aim of the current study was to present the results of 10 cases treated with arthroplasty following a gunshot injury to the hip joint together with the recommended treatment algorithm. METHODS Patients with a previous medical history of hip joint region gunshot injury who underwent total hip arthroplasty were retrospectively evaluated. Those with incomplete medical records or who were lost to follow-up were excluded. Patients were classified according to the severity of the previous gunshot injury to the hip joint region. Harris hip score (HHS) and Short Form-12 quality of life score were the main outcome measurements. Postoperative complications encountered during follow-up were recorded. RESULTS The mean age of the patients at the time of surgery was 29.9 years. The mean preoperative HHS was 25.2 points and it was 65.8 at the final follow-up. Patients with bullet fragments in the hip joint, classified as group 1, had better HHS, whereas those with contaminated hip joint with intestinal flora, classified as group 3, had worst HHS. CONCLUSION Hip arthroplasty after hip joint gunshot injury is a good treatment choice in young patients to reduce pain and regain functions. However, very high infection rates can be seen in patients with accompanying intestinal injury.
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Affiliation(s)
- Ozhan Pazarci
- Department of Orthopaedics and Traumatology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Seyran Kilinc
- Department of Orthopaedics and Traumatology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Yalkin Camurcu
- Department of Orthopaedics and Traumatology, Erzincan University School of Medicine, Erzincan, Turkey
| | - Okay Bulut
- Department of Orthopaedics and Traumatology, Cumhuriyet University School of Medicine, Sivas, Turkey
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Riva F, Mattijssen EJAT, Kerkhoff W. Rifle bullet deflection through a soft tissue simulant. Forensic Sci Int 2018; 291:199-206. [PMID: 30218867 DOI: 10.1016/j.forsciint.2018.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/20/2018] [Accepted: 08/21/2018] [Indexed: 11/26/2022]
Abstract
Trajectory deflections of 5.56 NATO and 7.62×39mm rifle bullets, fired through 7.5, 15 and 22.5cm of gelatine, were studied. The magnitude of the deflections from the bullets' original trajectories after perforation are related to the length and the profile of the (wound) channels through gelatine. After 7.5cm of penetration depth, deflection was less than 1°. With the longer channel lengths, bullet instability set in and subsequently, deflection was much larger. Deflection was highest with fragmented 5.56 NATO bullets after perforating 22.5cm of gelatine. The data from this study can be used to assess the degree of bullet deflection in trajectory reconstructions after incidents where human bodies were perforated with rifle bullets of the respective calibres and cartridge types.
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Affiliation(s)
- F Riva
- Institut für Rechtsmedizin (IRM) Bern, Bühlstrasse 20, 3012 Bern, Switzerland.
| | - E J A T Mattijssen
- Netherlands Forensic Institute (NFI), P.O. Box 24044, 2490 AA The Hague, The Netherlands
| | - W Kerkhoff
- Netherlands Forensic Institute (NFI), P.O. Box 24044, 2490 AA The Hague, The Netherlands
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15
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Nalli NR. Gunshot-wound dynamics model for John F. Kennedy assassination. Heliyon 2018; 4:e00603. [PMID: 29736430 PMCID: PMC5934694 DOI: 10.1016/j.heliyon.2018.e00603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/01/2018] [Accepted: 04/06/2018] [Indexed: 12/04/2022] Open
Abstract
U.S. President John F. Kennedy was assassinated while riding in an open motorcade by a sniper in Dallas, Texas on 22 November 1963. A civilian bystander, Mr. Abraham Zapruder, filmed the motorcade with a 8-mm home movie camera as it drove through Dealey Plaza, inadvertently recording an ≈8 second sequence of events that included a fatal gunshot wound to the President in the head. The accompanying backward motion of the President's head after impact appeared to support later “conspiracy theories” because it was claimed that this was proof of a shot from the front (in addition to one from behind). In this paper, simple one-dimensional dynamical models are uniquely applied to study in detail the fatal shot and the motion of the President's head observed in the film. Using known parameters from the crime scene, explicit force calculations are carried out for determining the projectile's retardation during tissue passage along with the resulting transfer of momentum and kinetic energy (KE). The computed instantaneous KE transfer within the soft tissue is found to be consistent with the formation of a temporary cavity associated with the observed explosion of the head, and subsequent quantitative examination of this phenomenon reveals two delayed forces at play in the backward motion of the President following impact. It is therefore found that the observed motions of President Kennedy in the film are physically consistent with a high-speed projectile impact from the rear of the motorcade, these resulting from an instantaneous forward impulse force, followed by delayed rearward recoil and neuromuscular forces.
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Affiliation(s)
- Nicholas R Nalli
- I.M. Systems Group, Inc., 5825 University Research Court, College Park, MD 20740, USA
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16
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Emergency Treatment of Blast, Shell Fragment and Bullet Injuries to the Central Midface Complex. J Maxillofac Oral Surg 2018; 18:124-130. [PMID: 30728703 DOI: 10.1007/s12663-018-1107-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022] Open
Abstract
Purpose Current ballistics and high-energy explosion possess unnoticed, new and significant biophysics and pathophysiology wounding effects that are unique in comparison with civilian trauma. The primary blast wave effects of compressed air due to explosion lead to tattered and crushed eggshell injuries to the upper central midface (UCM). High-energy shell fragments of various shapes and sizes cause extensive destruction and are different from assault rifle's bullets that cause high energy transfer to the tissue by creating a temporary cavitation. Methods Twenty-one patients with unquantifiable war injuries were selected. The emergency managment of lifesaving facial war injuries starts with life threatening hemorrahge or air compramise. This article describes immediate management of medial canthal tendon (MCT), intercanthal region and severe nasal war injuries. Results The utilized procedure obtained good results compared to the results of cases treated only by applying a classic approach of civilian fractures. Conclusion Treatments of UCM injuries are the most difficult since UCM includes the esthetic, physiologic, and anatomical regions of the face. The proposed technique provides immediate excellent stability for soft tissues, bone, and cartilage and is well tolerated in the long term by both the tissue and the patient. Most of the times, victims are treated with limited resources, deficient subspecialty, massive injuries, during mass casualties, and a single surgeon must have to handle all these within a short period of time. UCM injuries are really concerning since this region is the core of facial esthetic and function.
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17
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Giaquinta A, Mociskyte D, D'Arrigo G, Barbagallo G, Certo F, Veroux M, Veroux P. Penetrating aortic injury left untreated for 20 days: a case report. BMC Surg 2018; 18:6. [PMID: 29374465 PMCID: PMC5787315 DOI: 10.1186/s12893-018-0337-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Penetrating aortic trauma remains one of the most challenging injuries with a high mortality rate if left untreated, or if the surgical treatment is delayed. We present an uncommon case of a late diagnosed abdominal firearm injury, in which the bullet partially penetrated the wall of the aorta, creating a plug that prevented immediate death due to massive bleeding. CASE PRESENTATION A 26-year-old Libyan man was a victim of a firearm wound, with a bullet penetrating his abdominal wall from the left to right side. After the assault, the victim, spent up to 20 days crossing the Mediterranean Sea to leave his country of origin. Abdominal radiography revealed the presence of a bullet located anteriorly to the second lumbar vertebra, while computed tomography angiography, unexpectedly, demonstrated that the bullet penetrated partially into the aortic wall at the level of the left renal artery. The bullet penetrated the aortic wall for half of its length, creating a plug that avoided immediate life-threatening bleeding at the time of the gunshot injury. The bullet was removed and the aortic lesion was repaired. The patient was discharged 6 days after the surgical procedure, in good health. CONCLUSIONS We presented a very rare case of late diagnosis of aortic injury caused by a gunshot lesion, in which the particular trajectory of the bullet helped avoid immediate life-threatening bleeding and, probably, saved the patient's life.
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Affiliation(s)
- Alessia Giaquinta
- Vascular Surgery and Organ Transplant Unit, Department of Surgery, University Hospital of Catania, Via Santa Sofia, 84 95123, Catania, Italy
| | - Dovile Mociskyte
- Vascular Surgery and Organ Transplant Unit, Department of Surgery, University Hospital of Catania, Via Santa Sofia, 84 95123, Catania, Italy
| | - Giuseppe D'Arrigo
- Vascular Surgery and Organ Transplant Unit, Department of Surgery, University Hospital of Catania, Via Santa Sofia, 84 95123, Catania, Italy
| | - Giuseppe Barbagallo
- Neurosurgery Unit, Department of Surgery, University Hospital of Catania, Catania, Italy
| | - Francesco Certo
- Neurosurgery Unit, Department of Surgery, University Hospital of Catania, Catania, Italy
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, Department of Surgery, University Hospital of Catania, Via Santa Sofia, 84 95123, Catania, Italy.
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, Department of Surgery, University Hospital of Catania, Via Santa Sofia, 84 95123, Catania, Italy
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18
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Shaqiri E, Xhemali B, Ismaili Z, Sinamati A, Vyshka G. An unusual lethal gunshot wound to the head. Med Leg J 2017; 85:51-54. [PMID: 27837166 DOI: 10.1177/0025817216678718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Atypical gunshot wounds present a challenge for the forensic expert, and sometimes differentiating these from a blunt trauma can be difficult. A careful crime scene investigation can be helpful in finding additional evidence and clarifying the nature of the injuries. We describe a case of an unusual craniocerebral injury that was initially interpreted as a blow from a wooden object. The appearance of the wound lacked the classical characteristics of entrance and exit bullet wounds, but the investigation showed it was due to the ricocheting of a destabilized bullet. Potentially lethal, craniocerebral gunshot injuries are a common occurrence in developing countries even in non-conflict areas, with very bad outcomes even when treated aggressively in specialized neurosurgical facilities. The authors briefly discuss similar cases and opinions in the relevant literature, emphasizing the importance of a rational approach during the reconstruction of the crime scene.
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Affiliation(s)
- Elmas Shaqiri
- 1 Department of Forensic Pathology, Institute of Legal Medicine, Tirana, Albania
| | - Bledar Xhemali
- 1 Department of Forensic Pathology, Institute of Legal Medicine, Tirana, Albania
| | - Zija Ismaili
- 1 Department of Forensic Pathology, Institute of Legal Medicine, Tirana, Albania
| | - Admir Sinamati
- 1 Department of Forensic Pathology, Institute of Legal Medicine, Tirana, Albania
| | - Gentian Vyshka
- 2 Faculty of Medicine, University of Medicine in Tirana, Tirana, Albania
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19
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Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol 2017; 24:301-309. [DOI: 10.1007/s10140-016-1477-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/22/2016] [Indexed: 12/24/2022]
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Mei QY, Li Y, He C, Shan HW, Wang YK, Dong Y, Yu MK, Hou LJ. Combination of dura turning-over and decompressive craniectomy: a new pattern of surgery for cerebral infarction caused by craniocerebral gunshot injury. Mil Med Res 2017; 4:26. [PMID: 28828175 PMCID: PMC5561627 DOI: 10.1186/s40779-017-0135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/04/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue, resulting in the loss of function of a certain area or other fatal damage to the human brain. Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare, accounting for the majority of battle casualties. Most of the patients suffer from acute cerebral infarction caused by vascular injury. Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded. CASE PRESENTATION We present a 24-year-old man who was shot with a shotgun from a distance of 15 m in an accidental injury. Forty-seven grapeshots were found on his body surface by physical examination. A computed tomography (CT) scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later. Afterwards, the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai. Cranial computed tomography angiography (CTA) showed a high-density shadow in the initial part of the right middle cerebral artery. The branches after the initial part were obliterated. Prompt medical attention and decompressive craniotomy (DC) surgery contributed to the final recovery from cerebral infarction of this patient. CONCLUSION Bullets can penetrate or be lodged in the brain, causing intracranial hypertension. The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery, causing acute cerebral infarction. Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure, which can increase the blood supply for hypertension-induced vessel stenosis, but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex. However, this new pattern of surgery needs further support from evidence-based medicine.
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Affiliation(s)
- Qi-Yong Mei
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Yao Li
- Department of Hepatic Surgery III, Eastern Hepatobiliary Surgical Hospital, Shanghai, 200438 China
| | - Chao He
- Department of Emergency, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai, 200003 China
| | - Hong-Wei Shan
- Department of Emergency, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai, 200003 China
| | - Yun-Kun Wang
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Yan Dong
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Ming-Kun Yu
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Li-Jun Hou
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
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Humphrey C, Kumaratilake J. Ballistics and anatomical modelling – A review. Leg Med (Tokyo) 2016; 23:21-29. [DOI: 10.1016/j.legalmed.2016.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/22/2016] [Accepted: 09/05/2016] [Indexed: 01/02/2023]
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22
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Peonim V, Srisont S, Udnoon J, Wongwichai S, Thapon A, Worasuwannarak W. Entrance and exit wounds of high velocity bullet: An autopsy analysis in the event of dispersing the mass rally in Bangkok Thailand, May 2010. Leg Med (Tokyo) 2016; 23:10-16. [PMID: 27890096 DOI: 10.1016/j.legalmed.2016.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 08/07/2016] [Accepted: 08/25/2016] [Indexed: 11/24/2022]
Abstract
Fatal mass casualties by high velocity bullets (HVBs) are rare events in peaceful countries. This study presents 27 forensic autopsy cases with 32 shots fired by 5.56×45mm. HVB (M-16 rifle bullets) during the dispersing the mass rally in Bangkok Thailand, May 2010. It was found that twenty-three (71.88%) typical entrance HVB wounds had round sizes less than the bullet diameters. Most entrance wounds had microtears but no collar abrasion since a HVB has a small streamlined spitzer tip and full metal jacket. For exit wounds, there were various sizes and shapes depending on which section of wound ballistics presented when the bullet exited the body. If a bullet exited in the section of temporally cavity formation, there would be a large size exit wound in accordance with the degree of bullet yaw. This is different from civilian bullets whereby the shape looks like a cylindrical round nose and at low velocity that causes entrance wounds with a similar size to the bullet diameter and is usually round or oval shape with collar abrasion. The temporary cavity is not as large as in a HVB so exit wounds are not quite as large and present a ragged border compared to a HVB. We also reported 9 out of 32 shots (28.13%) of atypical entrance wounds that had various characteristics depending on site of injury and destabilization of bullets. These findings may be helpful to forensic pathologists and to give physicians, who need to diagnose HVB wounds, more confidence.
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Affiliation(s)
- Vichan Peonim
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Smith Srisont
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jitta Udnoon
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sompong Wongwichai
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Arisa Thapon
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisarn Worasuwannarak
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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