Aide memoire for the management of gunshot wounds

Ballistic research techniques: visualizing gunshot wounding patterns

There are difficulties associated with mapping gunshot wound (GSW) patterns within opaque models. Depending on the damage measurement parameters required, there are multiple techniques that can provide methods of "seeing" the GSW pattern within an opaque model. The aim of this paper was to test several of these techniques within a cadaveric animal limb model to determine the most effective. The techniques of interest were flash X-ray, ultrasound, physical dissection, and computed-tomography (CT). Fallow deer hind limbs were chosen for the model with four limbs used for each technique tested. Quarantined 7.62 × 39 mm ammunition was used for each shot, and each limb was only shot once, on an outdoor range with shots impacting at muzzle velocity. Flash X-ray provided evidence of yaw within the limb during the projectile's flight; ultrasound though able to visualise the GSW track, was too subjective and was abandoned; dissection proved too unreliable due to the tissue being cadaveric so also too subjective; and lastly, CT with contrast provided excellent imaging in multiple viewing planes and 3D image reconstruction; this allowed versatile measurement of the GSW pattern to collect dimensions of damage as required. Of the different techniques examined in this study, CT with contrast proved the most effective to allow precise GSW pattern analysis within a cadaveric animal limb model. These findings may be beneficial to others wishing to undertake further ballistic study both within clinical and forensic fields.

Tudor military surgery and the management of Sir Martin Frobisher's gunshot wound: Comparison with current treatment

Sir Martin Frobisher (ca 1535-1594), the famous Elizabethan explorer and privateer, sustained a bullet to the outer plate of his ilium from a low-velocity bullet wound fired at close range from an arquebus, an early form of musket. The bullet was removed, but he subsequently died from gas gangrene. This paper looks at the management of this injury in Tudor times and compares it to current practice. The arrival of gunpowder and the seriousness of the resulting injuries spurred innovation in surgical practice, such that at the time of Frobisher's death, the Tudor military surgeon had considerable expertise and skill. The wound, treated properly, was not serious, but his first surgeon failed to remove the wadding that the bullet took with it. This was recognised as an error at the time. A Tudor surgeon today would note that the surgical management has not really changed since their time, even though they did not understand infection and bacterial contamination. Guidelines on managing gunshot wounds, and most research, is focussed on high-velocity injuries where removal of foreign material (clothing) is mentioned. Low-velocity injuries are treated as "outpatients" and the importance of removing foreign material, especially when the bullet is left in situ, is not mentioned. The inexperienced surgeon of today risks making the same error as Frobisher's surgeon.

Venous Shunt Versus Venous Ligation for Vascular Damage Control: The Immunohistochemical Evidence

BACKGROUND

To evaluate the expression of immunohistochemical markers of tissue ischemia (iNOS, eNOS, and HSP70) in a vascular damage control experimental model to determine if a venous temporary vascular shunt insertion leads to a better limb perfusion when compared with the ligature of the injured vein.

METHODS

Experimental study in male Sus Scrofa weighting 40 Kg. Animals were distributed into 5 groups: group 1 animals were submitted to right external iliac artery (EIA) shunting and right external iliac vein (EIV) ligation; group 2 animals were submitted to right EIA shunting and right EIV shunting; group 3 animals were submitted to right EIV ligation; group 4 animals were submitted to right EIV shunting; group 5 animals were not submitted to vascular shunting or venous ligation. Transonic Systems flowmeters were used to measure vascular flow on right and left external iliac vessels, and i-STAT (Abbot) portable blood analyzer was used for EIVs blood biochemical analysis. An initial baseline register of invasive arterial pressure, iliac vessels flow, and venous blood analysis was performed. Arterial pressure and iliac vessels flow were taken immediately after right iliac vessels shunting or ligation. Then, hemorrhagic shock was induced by continuous 20 mL/min blood withdraw from the external right jugular vein whereas arterial blood pressure and iliac vessels flow registers were taken every 10 min, and blood samples from EIVs were obtained every 30 min until the vascular flow through right EIA (or through the shunt inserted into the right EIV for group 4 animals) became inexistent or until the animal's death. After the end of the experiments, bilateral hind limb's biopsies were obtained for immunohistochemical analysis. Using image editing and analysis software, the expression of iNOS, eNOS, and HSP70 (3 well-known ischemic associated immunohistochemical markers) was assessed. The mean expression of each marker in the right hind limb was compared between groups. For statistical analysis, Microsoft Office Excel 2007 and BioEstat 5.0 (2007) were used.

RESULTS

Immunohistochemical analysis showed no difference regarding the iNOS expression; nevertheless, both eNOS and HSP70 expression were statistically more intense (P < 0.05) on group 1 (eNOS = 1.32; HSP70 = 15.05) than on group 2 (eNOS = 0.018; HSP70 = 8.56).

CONCLUSIONS

The higher expression of eNOS and HSP70 in the right hind limbs of group 1 animals (arterial shunt and venous ligature) than group 2 animals (arterial shunt and venous shunt) suggests that venous ligation is associated with more intense ischemic histological findings than venous shunting.

The early hospital management of gunshot wounds. Part 1: head, neck and thorax

The management of gunshot wounds is an increasing problem for UK emergency doctors, but not to an extent where it has become routine or allowed individuals to gain significant experience in their treatment. This article reviews the pathophysiology of gunshot injury in general before examining the evidence available concerning the management of gunshot wounds to the head neck and thorax.

Initial surgical management of a gunshot wound to the lower face – a stepwise approach

Facial gunshot wounds are rarely encountered in the UK, but not to such an extent that emergency departments should not be prepared to deal with them. We describe the management of a self-inflicted shotgun wound to the lower face using a step-wise approach. The primary reconstruction of such injuries should be performed soon after stabilisation of the patient. Simple yet careful surgical techniques are often effective in cases of severe facial trauma that might initially appear to require tissue transfer techniques, as soft tissue loss is often less than initially estimated. Preservation and closure of remaining tissue should aim to reconstruct oro-facial units while leaving options for more advanced reconstructive techniques open for future procedures if necessary.

[Management of penetrating abdominal trauma: what we need to know?]

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.