Vicq, P; Jourdan, P; Chapuis, O; Baranger, B
The mortality from abdominal gunshot wounds remains high, either in civilian or military cases. The severity factors of these wounds include bullet calibre and energy transfer of the missile. This paper studies some of the ballistics features of abdominal gunshot wounds. Practical guidelines are inferred concerning diagnosis and treatment of these wounds.
Mctyre, Emory; McGill, Lee; Miller, Nessa
Missile pulmonary emboli are rare sequelae of traumatic entry of projectile missiles-generally bullets or bullet fragments-in which access to the systemic venous circulation is established by the missile, making it possible for the missile to migrate to the pulmonary arteries. In the case introduced here, a 24-year-old male presented to the ER with a gunshot wound to the abdomen. In the early course of his care, it was determined that he had suffered a missile pulmonary embolus secondary to a large fragment of a bullet penetrating the IVC. Despite the large perfusion defect created by this missile embolus, the patient recovered uneventfully without embolectomy.
Ignjatović, Dragan; Misović, Sidor; Jevtić, Miodrag
To present a patient with an indirect secondary non-perforating blast injury of the right colon following abdominal gunshot injury, which led to necrosis and the right colon gangrene, and was surgically managed. A 26-year-old male was shot in the abdomen by four projectiles causing the secondary indirect blast injury of the right colon that turned into gangrene after 24 hours. Two days after admission, laparotomy was performed, but the primary anastomosis was not done because of the stomach and pancreatic injury, and the resection of the colon with terminal ileostomy was done instead. Three months later, the reconstruction of the colon was performed using ileocolotransverso-terminolatetral anastomosis. Secondary blast injuries should be anticipated in gunshot injuries, and could be expected to any organs, particularly the air filled ones.
Gorgulu, Semih; Gencosmanoglu, Rasim; Akaoglu, Cuneyt
The aim of this study was to present the outcomes of military penetrating abdominal gunshot injuries, to identify factors that predict morbidity, and to compare the present results with those from two civilian trauma centers. Fifty-one consecutive patients who had suffered high-velocity gunshot wounds to the abdomen were assessed retrospectively. Penetrating abdominal trauma index, the number of injured organs, and the presence of colonic injury were significantly associated with high morbidity by univariate analysis. Multivariate analysis showed that only the number of organs injured and presence of colonic injury were independent predictors of morbidity. Our results showed that military rifle bullets do not cause greater tissue disruption than that found in wounds created by lower-velocity projectiles. The presence of colonic injury and the number of organs injured (more than three) seem to be important predictors of morbidity in penetrating abdominal gunshot wounds caused by high-velocity missiles.
White, K M
The severity of injury in a gunshot wound is dependent on many factors, including the type of firearm; the velocity, mass, and construction of the bullet; and the structural properties of the tissues that are wounded. Knowledge of ballistics and an appreciation of the wounding potential of certain firearms and their ammunition can help clinicians anticipate the severity of a wound and raise the index of suspicion for occult but severe internal trauma.
... wound References Simon BC, Hern HG. Wound management principles. In: Marx JA, Hockberger RS, Walls RM, et ... member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www. ...
Hennessy, M J; Banks, H H; Leach, R B; Quigley, T B
The civilian gunshot wound is a low velocity injury. Temporary cavitation does not occur in the low velocity wound and damage is confined to the projectile pathway. Extensive debridement is not indicated for this injury. Surgical cleansing is used to convert the open, contaminated wound to a clean, closed wound. Reparative and definitive reconstruction then follow to restore form and function with minimized patient hazard.
Peleg, Michael; Sawatari, Yoh
The gunshot wound to the mandible is a unique traumatic injury. The resultant injury from the gunshot wound is diverse because of the variability of the projectile, motion, velocity, and tissue characteristics. When a high-velocity projectile strikes the mandible, often times the wound will consist of a severely comminuted mandible surrounded by nonvital soft tissues and the implantation of multiple foreign bodies. This represents a challenge for the treating surgeon. The anatomy and function of the mandible make it such that the care of the gunshot wound requires a combination of trauma and reconstructive surgeries. There are varying techniques advocated for the management of gunshot wound to the face. However, for the comminuted mandible fracture sustained from a gunshot wound, an approach involving the fabrication of an occlusal splint, intermaxillary fixation, aggressive debridement of hard and soft tissues, and immediate reconstruction with a titanium plate is a comprehensive approach that can restore the appropriate function and contour of the patient. At the Division of Oral and Maxillofacial Surgery, University of Miami, this approach to the comminuted mandible fracture secondary to the gunshot wound has led to the effective management of this specific subset of injury. The complication rate is comparable with the current literature and provides an advantage as a 1-stage management to restore appropriate function and cosmesis to the patient.
Dougherty, Paul J; Najibi, Soheil; Silverton, Craig; Vaidya, Rahul
The extremities are the most common anatomic location for gunshot wounds. Because of the prevalence of gunshot injuries, it is important that orthopaedic surgeons are knowledgeable about caring for them. The most common injuries seen with gunshot wounds are those of the soft tissues. Nonsurgical management of patients who have gunshot wounds with minimal soft-tissue disruption has been successfully accomplished in emergency departments for several years; this includes extremity wounds without nerve, intra-articular, or vascular injury. Stable, nonarticular fractures of an extremity have also been successfully treated with either minimal surgical or nonsurgical methods in the emergency department. Indications for surgical treatment include unstable fractures, intra-articular injuries, a significant soft-tissue injury (especially with skin loss), vascular injury, and/or a large or expanding hematoma.
Shvyrkov, Michael B
Over the period 1981-1985 the author treated 1486 patients with facial gunshot wounds sustained in combat in Afghanistan. In the last quarter of 20th century, more powerful and destructive weapons such as M-16 rifles, AK-47 and Kalashnikov submachine guns, became available and a new approach to gunshot wound debridement is required. Modern surgeons have little experience in treatment of such wounds because of rare contact with similar pathology. This article is intended to explore modern wound debridement. The management of 502 isolated soft tissue injuries is presented. Existing principles recommend the sparing of damaged tissues. The author's experience was that tissue sparing lead to a high rate of complications (47.6%). Radical primary surgical debridement (RPSD) of wounds was then adopted with radical excision of necrotic non-viable wound margins containing infection to the point of active capillary bleeding and immediate primary wound closure. After radical debridement wound infection and breakdown decreased by a factor of 10. Plastic operations with local and remote soft tissue were made on 14, 7% of the wounded. Only 0.7% patients required discharge from the army due to facial muscle paralysis and/or facial skin impregnation with particles of gunpowder from mine explosions. Gunshot face wound; modern debridement. Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Rapkiewicz, Amy V; Tamburri, Robert; Basoa, Mark E; Catanese, Charles A
MagSafe ammunition is a type of unconventional prefragmented ammunition. A fatal tangential gunshot wound involving MagSafe ammunition is presented. The ammunition and wound characteristics are discussed.
Sun, Gordon H; Patil, Yash J; Harmych, Brian M; Hom, David B
Microvascular free tissue transfer (FTT) is an increasingly used method of reconstruction for traumatic defects of the head and neck. We describe the immediate management, FTT reconstruction techniques, and outcomes of 6 individuals who sustained maxillofacial gunshot trauma and were treated at a single tertiary-care level I trauma center. All 6 patients were white men with a mean age of 33 years. The mandible, nose, and orbital contents were the most frequently affected critical structures. All patients initially underwent primary wound debridement and tracheostomy, with concurrent maxillomandibular wire fixation and/or midface or mandible plate fixation in 5 patients. The mean time from injury to definitive FTT was 38 days. Five patients underwent fibula osteocutaneous FTT and 1 underwent radial forearm fasciocutaneous FTT. One patient also underwent concurrent local tissue rearrangement and pedicled flap surgery for nasal reconstruction. The mean hospital length of stay after FTT was 6 days. All FTT survived without necrosis. Oral incompetence and poor cosmesis from undesirable scarring patterns were the most common long-term complications. In summary, successful reconstruction of head and neck defects caused by gunshot trauma begins with airway stabilization, wound management, and bony fracture reduction and fixation. Definitive microvascular FTT is a useful method of repairing traumatic head and neck defects, although long-term functional and cosmetic complications may still occur.
Kaufman, Yoav; Cole, Patrick; Hollier, Larry H.
Facial gunshot wounds, often comprising significant soft and bone tissue defects, pose a significant challenge for reconstructive surgeons. Whether resulting from assault, accident, or suicide attempt, a thorough assessment of the defects is essential for devising an appropriate tissue repair and replacement with a likely secondary revision. Immediately after injury, management is centered on advanced trauma life support with patient stabilization as the primary goal. Thorough examination along with appropriate imaging is critical for identifying any existing defects. Whereas past surgical management advocated delayed definitive treatment using serial debridement, today’s management favors use of more immediate reconstruction. Recent advances in microsurgical technique have shifted favor from local tissue advancement to distant free flap transfers, which improve cosmesis and function. This has resulted in a lower number of surgeries required to achieve reconstruction. Because of the diversity of injury and the complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is achieved. PMID:22110801
Aryan, Henry E; Amar, Arun P; Ozgur, Burak M; Levy, Michael L
The incidence of spinal instability after penetrating gunshot wounds to the spine in adolescents is unknown. We describe our experience over a 15-year period. Hospital records were reviewed retrospectively. After injury and emergency care, patients were transferred to a rehabilitation facility. Examinations were completed using the American Spinal Injury Association and Frankel scales on admission, discharge, and 6 and 12 months after injury. Severity of injury was described by: 1) degree of neurological damage, 2) degree of preserved neurological function, and 3) presence of instability. Sixty patients were identified with a mean age 15.6 years (+/- 2.7 yr). Twelve patients had cervical, 31 thoracic, and 17 lumbosacral injuries. No operative treatments were used in their care. Thirty-four patients had complete neurological deficits. Mean acute hospitalization was 21.1 days (+/- 22.8 d), and mean rehabilitation stay was 86.3 days (+/- 48.9 d), for a total hospitalization of 107.4 days (+/- 65.9 d). At 1 year, 19 patients were ambulatory and 53 were autonomous. Despite the presence of bony involvement in all, no evidence of spinal instability was noted on follow-up dynamic imaging. Even in two patients with apparent two-column disruption, no instability was noted. At 1-year follow-up, significant (nonfunctional) improvement was noted in the neurological examination (P < 0.0001). Improvements were most notable in those patients with cervical injuries, followed by thoracic and lumbar injuries. After penetrating gunshot wounds to the spine, patients at 1-year follow-up examinations have evidence of significant, but nonfunctional, improvement. No evidence of spinal instability was noted in this study, and no surgical intervention was required.
Perez, Danielo B; Molina, D Kimberley
Determining the range of fire is a crucial part of a forensic examination of gunshot wound victims. Traditionally, this has been accomplished by noting the gross appearance of soot or powder around the wound. This study was undertaken to determine the utility of routine histological examination of gunshot wounds as related to range-of-fire determination. A prospective study was performed, and a total of 69 gunshot wounds were examined both macroscopically and microscopically. Of the 45 entrance wounds examined, there was 100% concordance between macroscopic and microscopic analysis for the close-range wounds and 67% concordance for the distant wounds, with 33% of these wounds showing no evidence of soot or powder grossly but where residue was seen microscopically. In addition, 21% of the exit wounds examined showed microscopic evidence of soot/powder residues when none were visible macroscopically. As described in previous studies, it can be assumed that the bullet itself can deposit small residues along the wound track (bullet wipe) that can be seen microscopically and is unrelated to the range of fire. Therefore, the authors conclude there is no utility in the routine histological examination of gunshot wounds for the determination of range of fire.
DeCuypere, Michael; Muhlbauer, Michael S; Boop, Frederick A; Klimo, Paul
OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St
Joseph, Bellal; Aziz, Hassan; Pandit, Viraj; Kulvatunyou, Narong; O'Keeffe, Terence; Wynne, Julie; Tang, Andrew; Friese, Randall S; Rhee, Peter
Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain. We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation. There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs. Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain. Published by Elsevier Inc.
Hlavaty, Leigh; Avedschmidt, Sarah; Root, Kelly; Amley, Jeffrey; Sung, LokMan
Proper interpretation of gunshot wounds is vital for the forensic pathologist and requires experience and expertise, as well as consultation with a firearms and ballistics expert and careful scene investigation in cases of atypical gunshot wounds. This study is the first large-series examining ricochet gunshot wounds involving different firearm calibers. Typical gunshot wounds created from 4 handgun calibers (22 Long Rifle, 9 × 19 mm Parabellum, .40 Smith &Wesson, and .45 Automatic Colt Pistol) and 2 rifle calibers (5.56 and 7.62 mm) were compared with wounds caused by bullets of those same calibers ricocheting off commonly encountered surfaces (concrete, asphalt, aluminum traffic signs, clay brick, and dry wall). Porcine skin, a human skin analog, attached to sheets of cardboard serviced as witness panels for capturing the entrance wounds. Examination of over 150 handgun and rifle entrance wounds established that every caliber and every ricochet surface resulted in atypical features, including irregularity in size or shape, lack of marginal abrasion, or other injuries on the surrounding skin. The most significant factor influencing the variability of the ricochet wounds was the surface the bullet deflected off before striking the body.
Moye-Elizalde, G A; Ruiz-Martínez, F; Suarez-Santamaría, J J; Ruiz-Ramírez, M; Reyes-Gallardo, A; Díaz-Apodaca, B A
Since 2007, Ciudad Juárez, Chihuahua has been considered as one of the most violent cities in the world. The General Hospital in this city is the main facility where patients with gunshot wounds are taken. The increased number of admissions of patients with these injuries to many hospitals in the country deserves special attention, as it has an impact on hospital resources and management protocols. To disseminate the epidemiology of fractures caused by gunshot wounds and the hospital care of these patients. A retrospective, observational cohort study was conducted of patients admitted to the Traumatology and Orthopedics Service, Cd. Juárez General Hospital, in Chihuahua, Mexico, from January 2008 to December 2010. All of them sustained fractures resulting from gunshot wounds. A total of 1281 patients with a diagnosis of gunshot wounds were admitted to the hospital; 402 of them were included in this study with 559 fractures; 329 were males and 73 females. Of the 559 fractures, 257 involved the upper limb, 294 the lower limb, and 8 the pelvis. Gunshot wounds-related fractures were classified according to the Gustilo classification. Seventy-nine patients had grade I fractures, 302 grade III, and 21 patients had both grades. Conservative treatment was used in 44.3% of fractures and osteosynthesis in 55%. One patient underwent amputation upon admission. The most widely used osteosynthesis methods were external fixator (37%), straight plates (21%) and intramedullary nail (17%). Five patients (1.3%) underwent amputation: two with femur fracture and 3 with humeral fracture. There were 27 deep infections (6%); one of them resulted in late amputation of the pelvic limb. The most common associated injuries included: chest injuries in 20 patients and abdominal injuries in 17. The range of hospital stay was 1-18 days, with a mean stay of 11 days. The overall mortality rate considering the total number of patients admitted (1,281) was 99 patients (7.72%). From 2006 to 2010 the
The hospitals in Johannesburg deal with about 4,000 gunshot wounds a year. Although most are from hand guns, a number are from high velocity, military-type weapons. Extensive experience has been built up and many lessons learned. Attention is directed to the actual damage inflicted rather than on theoretical predictions based on presumed velocity of the bullets involved, as this can often be misleading. Some patients are delayed in their presentation to emergency departments, in other cases several gunshot wound patients arrive at the same time, requiring appropriate triage and urgent management. PMID:12215024
Plattner, T; Kneubuehl, B; Thali, M; Zollinger, U
The goal of this study was the reproduction of shape and pattern of gunshot residues in near contact and contact gunshot wounds by a series of experimental gunshots on a skin and soft tissue model. The aim was to investigate the shape and direction of soot deposits with regard to the muzzle according to different muzzle-target angles, firing distances, type of ammunition and weapon and barrel length. Based on a review of the literature and on the results of the experiments the authors could make the following statements of gunshot residues in angled contact and close contact gunshot: (1) gunshot residues on the target surface can be differentiated in a "inner" and "outer powder soot zone"; (2) the outer powder soot zone is much less visible than the inner powder soot zone and may lack on human skin; (3) with increasing muzzle target distance both inner and outer powder soot halo increase in size and decrease in density; (4) in angled shots the inner powder soot halo shows an eccentric, elliptic shape which points towards the muzzle, regardless of ammunition, calibre and barrel length; (5) the outer powder soot points away from the muzzle in angled contact and close contact shots.
Beaty, Narlin; Slavin, Justin; Diaz, Cara; Zeleznick, Kyle; Ibrahimi, David; Sansur, Charles A
Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients
Schargus, M; Kawa, D; Elling, M; Kunkel, M
Orbital gunshot wounds are rarely found after suicide. A gunshot fired at point blank range into the temple has devastating effects on all intraorbital and neighboring structures. This article reports on two cases of gunshot wounds to the lateral orbit in attempted suicides with different weapons from 2012 and 2013 and treated at the Ruhr University Eye Hospital in Bochum. In both cases treatment was carried out in cooperation with the department of oral and maxillofacial surgery, Ruhr University Hospital, Bochum. In the first case a 7.65 mm gun was used. The patient presented with a double penetration of both orbits with total destruction of both globes and a reconstruction was not possible. The second patient presented with multiple shots to the head from a small caliber gun (5.6 mm) where one bullet entered the right orbit behind the globe. The bullet could be localized using computed tomography (CT) and surgically removed with preservation of the globe and with a postoperative visual acuity of 20/60. The preservation of visual function after orbital gunshot wounds depends on both the projectile channel and the characteristics of the gun and bullet. Close collaboration in surgical management between ophthalmologists, maxillofacial surgeons and neurosurgeons in specialized centers is necessary because patients often present with multiple trauma and prompt interdisciplinary treatment is needed.
Firat, Cemal; Geyik, Yilmaz
Maxillofacial traumas caused by gunshot wounds may cause quite varied defects. The objective of this study was to evaluate the reconstruction methods in 12 patients with gunshot wound-related mandibular and maxillofacial bony and soft tissue defects. Twelve patients who were operated on for maxillofacial gunshot wounds at our clinic between 2002 and 2012 were included in the study. Seven patients were wounded in a suicide attempt, and 5 were wounded as a result of an accident or in assaults. Two patients underwent reconstruction using free fibula osteocutaneous flap, 4 patients received the free radial forearm osteocutaneous flap, 2 patients received costal bone graft, and 3 patients received iliac bone grafts. Satisfactory functional and aesthetic outcomes were achieved in cases where staged secondary reconstruction, balloon treatment, and consecutive fat and steroid injections into the depressed scar areas were applied. In conclusion, the basic goal in maxillofacial reconstruction is the functional and aesthetic reconstruction of the contours. Because it is not easy to get perfect results with only 1 clinical approach or 1 method, the proper timing and reconstruction method should be selected.
Santucci, Richard A; Chang, Yao-Jen
Wound ballistics is a difficult subject. The behavior of all bullets is unpredictable but the specific effect of high velocity projectiles has been a particular source of confusion in the literature. This confusion has resulted in the likely incorrect conclusion that all high velocity wounds require massive débridement. We reviewed the entirety of the literature on this subject and concluded that high velocity weapons do not reliably create massive wounds, and judicious débridement and staged explorations may be the best treatment method for these patients. A MEDLINE search and retrieval were done of all pertinent references from 1966 to May 2003 concerning the field of wound ballistics. Articles initially missed in this search were obtained from the bibliography of retrieved studies. More than 70 articles and book chapters were reviewed. Five common myths about the tissue effects of gunshot wounds were reviewed as well as the data that dispel these myths. Information on the effects of different bullet types, and the intended and actual effect of military rifle wounds were assessed. For the majority of high velocity gunshot wounds, especially military rifles that generally fire a projectile that is meant to stay intact after impact, wound severity can be limited, even much less than that from a civilian rifle, shotgun or handgun. Judicious use of débridement during surgical exploration limits the extent of iatrogenic injury in the surgical care of these patients.
Talving, Peep; Nicol, Andrew J; Navsaria, Pradeep H
Low-velocity gunshot wounds cause most civilian duodenal injuries. The objective of this study was to describe a simplified surgical algorithm currently in use in a South African civilian trauma center and to verify its validity by measuring morbidity and mortality. A retrospective chart review of patients with duodenal gunshot injuries during the study period January 1999 to December 2003 was performed. Data points accrued included patient demographics, admission hemodynamic status and resuscitative measures, laparotomy damage control procedures, methods of surgical repair of the duodenal injury, associated injuries, length of intensive care and hospital stays, complications, and mortality. A total of 75 consecutive patients with gunshot injuries to the duodenum were reviewed. Primary repair was performed in 54 patients (87%), resection and reanastomosis in 7 (11%), and pancreatoduodenectomy in 1 (2%) during the initial phases. The overall morbidity and mortality were 58% and 28%, respectively. Duodenum-related complications were recorded in nine (15%) patients: two duodenal fistulas, one duodenal obstruction, and six cases of suture-line dehiscence. Overall and duodenum-related morbidity rates in patients with combined pancreatoduodenal injuries were 83% and 17%, respectively. Duodenum-related mortality occurred in three (4.8%) patients. Most civilian low-velocity duodenal gunshot injuries treated with simple primary repair result in overall morbidity, mortality, and duodenum-related complication rates comparable to those in reports where more complex surgical procedures were employed. Primary repair is also applicable for most combined pancreatic and duodenal gunshot injuries.
Aguilar, J C
Shored gunshot wound of exit is produced when the outstretched skin is impaled, sandwiched, and crushed between the outgoing bullet and the unyielding object over the exit site, thus leaving an abrasion collar on the wound margin. Proper coaptation of the wound margin is impossible because of the loss of skin just like those observed in entrance wounds. In contrast to the entrance wound, the supported exit wound shows a scalloped or punched-out abrasion collar and sharply contoured skin in between the radiating skin lacerations marginating the abrasion (Fig. 1). Should gunpowder be observed around the exit site, it is often unevenly distributed, and is not associated with searing, gunpowder stippled abrasion, tatooing, and deposition of soot.
Okoye, Obi T; Talving, Peep; Teixeira, Pedro G; Chervonski, Michael; Smith, Jennifer A; Inaba, Kenji; Noguchi, Thomas T; Demetriades, Demetrios
Transmediastinal gunshot wounds are associated with a high mortality and frequently require operative intervention. The purpose of this study was to identify the diagnostic and therapeutic challenges of these injuries in a mature trauma system with decreasing prehospital time intervals. Patients admitted to a large urban Level 1 trauma centre between 1/2006 and 12/2010 sustaining a firearm injury to the torso were identified. Transmediastinal gunshot wounds were defined as missile tracts traversing the mediastinum identified on CT images, operative notes or autopsy reports. Overall, 133 patients met study criteria. A total of 116 patients (87.2%) were haemodynamically unstable or had no vital signs on arrival to the Emergency Department. Ninety-seven (83.6%) of these patients required a resuscitative thoracotomy resulting in 8 survivors (6.0%). There were 17 haemodynamically stable patients (12.8%) identified, 14 of whom underwent CT scan evaluation. Six patients subsequently required operative intervention. Only 11 patients (8.3%) in the study population were successfully managed nonoperatively. The overall mortality was 78.9%, and for those who reached the hospital with vital signs, the mortality was 24.3%. Transmediastinal gunshot wounds encountered in a mature trauma centre are highly lethal injuries requiring resuscitative thoracotomy in most instances. Changing perspectives in these injuries may reflect the effects of an evolving prehospital care. Copyright © 2012 Elsevier Ltd. All rights reserved.
Swan, K G; Swan, R C
Ballistics is the science of the motion of a projectile through the barrel of a firearm (internal ballistics), during its subsequent flight (external ballistics), and during its final complicated motion after it strikes a target (terminal ballistics). Wound ballistics is a special case of terminal ballistics. Although wound ballistics is at best sets of approximations, its principles enter usefully into an evaluation of a gunshot wound and its treatment. A special consideration in these cases is their medicolegal aspects. At a minimum, the medical team receiving the patient should exert care not to destroy the clothing and in particular to cut around and not through bullet holes, to turn over to law enforcement officials any metallic foreign body recovered from the patient, and to describe precisely, or even to photograph, any entrance or exit wounds.
Wunnapuk, Klintean; Durongkadech, Piya; Minami, Takeshi; Ruangyuttikarn, Werawan; Tohno, Setsuko; Vichairat, Karnda; Azuma, Cho; Sribanditmongkol, Pongruk; Tohno, Yoshiyuki
To elucidate characteristics of gunshot residues in gunshot entry wounds with full-jacketed and lead bullets, element contents in entry gunshot wounds and control skins were analyzed by inductively coupled plasma-atomic emission spectrometry (ICP-AES). It was found that a high content of Fe and Zn was deposited in the gunshot entry wounds with full-jacketed bullet, whereas a high content of Pb was deposited in the gunshot entry wounds with lead (unjacked) bullet. It should be noted that the content of Pb was significantly higher in the gunshot entry wounds with lead bullet than in those with full-jacketed bullet. Regarding the relationships among elements, it was found that there were significant direct correlations between Pb and either Sb or Ba contents in both gunshot entry wounds with full-jacketed and lead bullets. As Pb increased in both gunshot entry wounds, Sb and Ba also increased in the wounds.
Lu, Huchen; Wang, Lian; Zhong, Wuzhao; Qi, Rongfeng; Li, Ning; You, Wanchun; Su, Xingfeng; Zhuang, Zong; Cheng, Huilin; Shi, Jixin
Bullet-induced brain wounds are common among military personnel in war zones and among civilians with gun accidents or crime-related gun injuries. The goal of this study was to develop a nonfatal porcine model of penetrating craniocerebral gunshot wound (PCGW) by firing a projectile in live swine to induce PCGW in such a realistic manner as to reconstruct their physical characteristics. We established a nonfatal porcine model of PCGW based on a custom-designed experimental gun that emulates the shooting of a 5.56-mm NATO standard rifle at 800 m (317 m/s; 200.9 J). Commercial swine (n = 20) were subjected to a ballistic wound to the bilateral frontal lobe, and four swine were used as controls. Surviving swine were used in subsequent first-aid, management, and monitoring experiments for neurosurgeons. Various physiological variables were measured continuously. After computed tomography (CT) scanning and three-dimensional CT reconstructions, all pigs underwent primary lifesaving emergency interventions, including emergency decompressive craniotomies and hemorrhage control. In our nonfatal porcine model of PCGW, injuries were comparable in their morphology to real gunshot wounds, as evidenced by analysis of wound characteristics and CT scan images. The survival rates of the pigs were 100% within 2 h, 95% within 6 h, 85% within 12 h, and 85% within 24 h (P < 0.01). Hemodynamics, hematology, blood routine biochemistry, coagulation, and other physiological parameters also exhibited significant changes in the PCGW pigs. This model makes possible the laboratory reproduction of real ballistic wounds in a live large animal model that is close to humans. Copyright © 2015 Elsevier Inc. All rights reserved.
In a 3-year period (1981-1984), 52 male patients aged 10-60 years were treated for fresh gunshot wounds. The injuries varied from minor soft tissue injuries to major organ and tissue damage, and were all sustained by low-velocity missiles. Six of the patients (11.5%) died of their injuries or complications while 46 (88.46%) survived and were discharged after 1-15 weeks (a mean hospital time of 3 weeks). Some of the patients were treated before referral and for some there was a delay of more than 48 h before definitive specialist treatment. Mortality was related to the severity of wounding and the delay before treatment. PMID:3620058
MacAulay, Lauren E; Barr, Darryl G; Strongman, Doug B
Previous studies document characteristics of gunshot wounds shortly after they were inflicted. This study was conducted to determine if the early stages of decomposition obscure or alter the physical surface characteristics of gunshot wounds, thereby affecting the quantity and quality of information retrievable from such evidence. The study was conducted in August and September, 2005 in Nova Scotia, Canada in forested and exposed environments. Recently killed pigs were used as research models and were shot six times each at three different ranges (contact, 2.5 cm, and 1.5 m). Under these test conditions, the gunshot wounds maintained the characteristics unique to each gunshot range and changes that occurred during decomposition were not critical to the interpretation of the evidence. It was concluded that changes due to decomposition under the conditions tested would not affect the collection and interpretation of gunshot wound evidence until the skin was degraded in the late active or advanced decay stage of decomposition.
İflazoğlu, Nidal; Üreyen, Orhan; Öner, Osman Zekai; Meral, Ulvi Mehmet; Yülüklü, Murat
In line with advances in diagnostic methods and expectation of a decrease in the number of negative laparotomies, selective non-operative management of abdominal gunshot wounds has been increasingly used over the last three decades. We aim to detect the possibility of treatment without surgery and present our experience in selected cases referred from Syria to a hospital at the Turkish-Syrian border. Between February 2012 and June 2014, patients admitted with abdominal gunshot wounds were analyzed. Computed tomography was performed for all patients on admission. Patients who were hemodynamically stable and did not have symptoms of peritonitis at the time of presentation were included in the study. The primary outcome parameters were mortality and morbidity. Successful selective non-operative management (Group 1) and unsuccessful selective non-operative management (Group 2) groups were compared in terms of complications, blood transfusion, injury site, injury severity score (ISS), and hospital stay. Of 158 truncal injury patients, 18 were considered feasible for selective non-operative management. Of these, 14 (78%) patients were treated without surgery. Other Four patients were operated upon progressively increasing abdominal pain and tenderness during follow-up. On diagnostic exploration, all of these cases had intestinal perforations. No mortality was observed in selective non-operative management. There was no statistically significant difference between Group 1 and Group 2, in terms of length of hospital stay (96 and 127 h, respectively). Also, there was no difference between groups in terms of blood transfusion necessity, injury site, complication rate, and injury severity score (p>0.05). Decision making on patient selection for selective non-operative management is critical to ensure favorable outcomes. It is not possible to predict the success of selective non-operative management in advance. Cautious clinical examination and close monitoring of these
Wunnapuk, Klintean; Minami, Takeshi; Durongkadech, Piya; Tohno, Setsuko; Ruangyuttikarn, Werawan; Moriwake, Yumi; Vichairat, Karnda; Sribanditmongkol, Pongruk; Tohno, Yoshiyuki
In order to discriminate bullet types used in firearms, of which the victims died, the authors investigated lead isotope ratios in gunshot entry wounds from nine lead (unjacketed) bullets, 15 semi-jacketed bullets, and 14 full-jacketed bullets by inductively coupled plasma-mass spectrometry. It was found that the lead isotope ratio of 207/206 in gunshot entry wounds was the highest with lead bullets, and it decreased in order from full-jacketed to semi-jacketed bullets. Lead isotope ratios of 208/206 or 208/207 to 207/206 at the gunshot entry wound were able to discriminate semi-jacketed bullets from lead and full-jacketed ones, but it was difficult to discriminate between lead and full-jacketed bullets. However, a combination of element and lead isotope ratio analyses in gunshot entry wounds enabled discrimination between lead, semi-jacketed, and full-jacketed bullets.
Payne, W K; Gabriel, R A; Massoud, R P
A retrospective review of 173 patient charts, angiograms, surgical reports, and plain radiographs were performed for all patients admitted with gunshot wounds to the thigh from May 1988 to January 1991 at Martin Luther King, Jr. Hospital. A zonal classification of gunshot wounds to the thigh was created and defined to determine if a zonal classification was predictive of a positive angiogram. Associations and relationships of patients with vascular injury are presented.
Tang, Zhen; Tu, Wenbing; Zhang, Gang; Chen, Yubin; Lei, Tao; Tan, Yinghui
Due to the complications arising from gunshot wounds to the maxillofacial region, traditional models of gunshot wounds cannot meet our research needs. In this study, we established a finite element model and conducted preliminary simulation and analysis to determine the injury mechanism and degree of damage for gunshot wounds to the human mandible. Based on a previously developed modelling method that used animal experiments and internal parameters, digital computed tomography data for the human mandible were used to establish a three-dimensional finite element model of the human mandible. The mechanism by which a gunshot injures the mandible was dynamically simulated under different shot conditions. First, the residual velocities of the shootings using different projectiles at varying entry angles and impact velocities were calculated. Second, the energy losses of the projectiles and the rates of energy loss after exiting the mandible were calculated. Finally, the data were compared and analysed. The dynamic processes involved in gunshot wounds to the human mandible were successfully simulated using two projectiles, three impact velocities, and three entry angles. The stress distributions in different parts of mandible after injury were also simulated. Based on the computation and analysis of the modelling data, we found that the injury severity of the mandible and the injury efficiency of the projectiles differ under different injury conditions. The finite element model has many advantages for the analysis of ballistic wounds, and is expected to become an improved model for studying maxillofacial gunshot wounds. Copyright © 2011 Elsevier Ltd. All rights reserved.
Verlicchi, A; Facchin, P; Zanotti, B
The authors present a case of a patient wounded to the head and back by civilian firearm projectiles. The case peculiarity is that only one bullet reached the brain stem level causing significant neurological deficits. The final clinical picture is comparable to the "caudal pontine tegmentum syndrome". The authors describe both the bullet path and the intracranial localization taking into account ballistic details. The problems associated with prognosis, diagnosis, and treatment for gunshot wounds are discussed. In addition, the authors explain the main intracranial lesions and their mechanisms, the role of investigation, and the protocol of medical and surgical treatment. Lastly, a systematic approach for treating these types of gunshot wounds is outlined.
Fais, Paolo; Giraudo, Chiara; Boscolo-Berto, Rafael; Amagliani, Alessandro; Miotto, Diego; Feltrin, Giampietro; Viel, Guido; Ferrara, S Davide; Cecchetto, Giovanni
Incineration or extensive burning of the body, causing changes in the content and distribution of fluids, fixation and shrinking processes of tissues, can alter the typical macroscopic and microscopic characteristics of firearm wounds, hampering or at least complicating the reconstruction of gunshot fatalities. The present study aims at evaluating the potential role of micro-computed tomography (micro-CT) for detecting and quantifying gunshot residue (GSR) particles in experimentally produced intermediate-range gunshot wounds severely damaged by fire. Eighteen experimental shootings were performed on 18 sections of human calves surgically amputated for medical reasons at three different firing distances (5, 15 and 30 cm). Six stab wounds produced with an ice pick were used as controls. Each calf section underwent a charring cycle, being placed in a wood-burning stove for 4 min at a temperature of 400 °C. At visual inspection, the charred entrance wounds could not be differentiated from the exit lesions and the stab wounds. On the contrary, micro-CT analysis showed the presence of GSR particles in all burnt entrance gunshot wounds, while GSR was absent in the exit and stab wounds. The GSR deposits of the firearm lesions inflicted at very close distance (5 cm) were mainly constituted of huge particles (diameter >150 μm) with an irregular shape and well-delineated edges; at greater distances (15 and 30 cm), agglomerates of tiny radiopaque particles scattered in the epidermis and dermis layers were evident. Statistical analysis demonstrated that also in charred firearm wounds the amount of GSR roughly correlates with the distance from which the gun was fired. The obtained results suggest that micro-CT analysis can be a valid screening tool for identifying entrance gunshot wounds and for differentiating firearm wounds from sharp-force injuries in bodies severely damaged by fire.
Nalli, Nicholas R
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.
Amadasi, Alberto; Mazzarelli, Debora; Merli, Daniele; Brandone, Alberto; Cattaneo, Cristina
The presence of "chipping" or "flaking" around the edges of gunshot entry wounds has been described among the characteristics of gunshot wounds in bone. In this study, the real frequency of such a peculiar feature was investigated. The presence of "chipping" was assessed on 22 gunshot wounds fired at a near-contact range on bovine ribs with 9-mm bullets. As controls, five samples were shot with a 3 cm range, and five from 40 cm. In 77% of cases shot at near-contact range, a detachment of small fragments of the upper layers of bone was detected, mainly with a circumferential disposition, whereas this feature was lacking in control samples. The study demonstrated the frequency of "chipping" and that it may probably be due to a combined ballistic effect of impact of the bullet itself and expansion of gases. It may be thus considered indicative of close-range shots. © 2016 American Academy of Forensic Sciences.
Bieler, D; Franke, A F; Hentsch, S; Paffrath, T; Willms, A; Lefering, R; Kollig, E W
The management of gunshot wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. Penetrating injuries occur with an incidence of 5% in Germany. They are caused by gunshots or more commonly by knives or other objects, for example during accidents. Since even the number of patients who are treated at level 1 trauma centres is limited by the low incidence, the objective of this study was to assess the epidemiology and outcome of gunshot and stab wounds in Germany. Since 2009, the trauma registry of the German Trauma Society (TraumaRegister DGU®) has been used to assess not only whether a trauma was penetrating but also whether it was caused by a gunshot or a stabbing. On the basis of this registry, we identified relevant cases and defined the observation period. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2011. We did not specify exclusion criteria in order to obtain as comprehensive a picture as possible of the trauma entities investigated in this study. As a result of the high incidence of gunshot wounds to the head and the implications of this type of injury for the entire group, a subgroup of patients without head injuries was analysed. From 2009 to 2011, there were 305 patients with gunshot wounds and 871 patients with stab wounds. The high proportion of suicide-related gunshot wounds to the head resulted in a cumulative mortality rate of 39.7%. Stab wounds were associated with a lower mortality rate (6.2%). Every fourth patient with a gunshot or stab wound presented with haemorrhagic shock, which was considerably more frequently seen during the prehospital phase than during the inhospital phase of patient management. Of the patients with gunshot wounds, 26.9% required transfusions. This percentage was three times higher than that for patients with blunt trauma. In Germany, gunshot and stab wounds have a low
Tholpady, Sunil S; DeMoss, Patrick; Murage, Kariuki P; Havlik, Robert J; Flores, Roberto L
Gunshot injuries to the craniomaxillofacial region are a challenge to the trauma and reconstructive surgeon. Although management of these injuries has been standardized and early rather than late intervention is advocated, the patient characteristics before, during, and after have been poorly elucidated. A prospectively maintained Level I trauma center database was queried as to gunshot wounds of the craniomaxillofacial skeleton. Over a five-year period (2007-2011), 168 patients were identified with these injuries. Charts were reviewed as to demographics, presentations, and outcomes and these were tested for significant relationships with hospital length of stay, numbers and types of procedures, morbidity, and mortality. Gunshot wounds to the craniofacial skeleton resulted in 71 deaths in this patient population. Those that died were significantly older, presented with a lower GCS, had a shorter LOS, and a higher INR than those that lived. Subgroup analysis of mechanism demonstrated mortality was more likely to occur as a result of self-inflicted injury in whites and due to assault in the African-American population. Data gathered from this study disputes some commonly held beliefs regarding the epidemiology of gunshot injuries and should allow for better characterization of which outcomes are consistent with which presentations. Published by Elsevier Ltd.
Solmaz, Ilker; Kural, Cahit; Temiz, Cağlar; Seçer, Halil Ibrahim; Düz, Bülent; Gönül, Engin; Izci, Yusuf
Traumatic brain injury (TBI) caused by a gunshot wound is a complex injury with a broad spectrum of symptoms and high rates of mortality and morbidity. This study presents an evaluation of TBI caused by gunshot wounds presenting at a single institution and discusses possible predictive factors for the outcome of surgical intervention. The study sample consisted of 442 patients who underwent surgery for TBI over a 16-year period. All injuries were caused by gunshot wounds, such as bullets and shrapnel. All patients underwent surgical intervention. Almost all patients (99.3%) were male, and the mean patient age was 22.3 years. Wounds were caused by shrapnel in 68 percent of patients. The Glasgow Coma Scale (GCS) score at admission was below 8 in 116 patients (26.2%) and above 8 in 326 patients (73.8%). In total, 47 patients (10.6%) died despite surgical management, with diffuse brain injury the most common cause of death. Low GCS scores, ventricular injuries and bihemispheric injuries are correlated with poor prognosis. Early and less invasive surgery in conjunction with short transportation time to the hospital could decrease mortality rates.
Bloch-Bogusławska, Elzbieta; Engelgardt, Piotr; Paradowska, Agnieszka
The Medical Forensic Institute, Collegium Medicum, Nicolaus Copernicus University in Bydgoszcz annually conducts approximately 600 autopsies. Gunshot wounds constitute only a small percentage of that number. The authors of this work have conducted an analysis of autopsy protocols prepared at the Institute in the years 1995-2005. During this period, 48 people were found dead as a result of gunshot wounds. This number constitutes 0.66% of all autopsies conducted within that time-frame. The objective of this study was an attempt at assessing the character of this phenomenon with due consideration given to the following parameters: age, sex, sobriety, circumstances and locality of the event, as well as season of the year, at comparing the results with data found in the literature on the subject.
Phillips, P; Hansraj, K K; Cox, E E; Ashley, E M
This article is a retrospective review of patients who presented to Martin Luther King, Jr./Drew Medical Center with gunshot wounds and had either isolated or associated injuries to the hand. The following is an account of those injuries noting the location, soft-tissue or bony involvement, and interventional methods that were implemented in the treatment of these patients who resided primarily in South Central Los Angeles. Prompt evaluation and initiation of treatment is essential in the management of both high- and low-velocity gunshot wounds so as to decrease the potential morbidity that often follows. Society must also look at the prevalence of these injuries and address the underlying issues that often are the root of the acts of violence.
Chowaniec, Czesław; Kobek, Mariusz; Jabłoński, Christian; Kabiesz-Neniczka, Stanisława; Karczewska, Weronika
The authors present a case of the death of a 60-year-old man shot using rubber projectiles that were fired by a police officer from a Mossberg smooth-bore shotgun in an enclosed space from a distance of a few metres. The post-mortem examination revealed that death had been due to gunshot wounds in the chest which had caused heart and lung damage with subsequent massive internal haemorrhaging.
Radford, G E; Taylor, M C; Kieser, J A; Waddell, J N; Walsh, K A J; Schofield, J C; Das, R; Chakravorty, E
Few studies have examined the biomechanical basis for backspatter from cranial gunshot wounds. Backspatter is material which travels against the direction of fire following ejection from a gunshot entrance wound. Our paper focuses on the use of animals for reconstructing this phenomenon. Five live pigs and several slaughtered pigs were shot using either 9 × 19 mm, 115 grain, full metal jacketed ammunition or .22 long rifle, 40 grain, lead, round-nose ammunition. A high-speed camera was used to record the entrance wound formation and backspatter. A small amount of backspattered material was produced with all targets, and blood backspatter was seen in a few cases. However, we conclude that our model provides an understanding of the phenomenon of backspatter and the physical mechanisms associated with it. The various components of the mechanism of backspatter formation are complex and overlap. The principle mechanism observed in pig cranial gunshots was the high-speed impact response of the skin overlying the skull bone. This study has also produced evidence supporting the view that backspatter can result from the splashing of superficial blood if it is already present on the skin. Subcutaneous gas effects have been demonstrated for backspatter from contact shots. There has been no clear evidence of the role of the collapse of a temporary cavity within the brain.
Kunkle, David A; Lebed, Brett D; Mydlo, Jack H; Pontari, Michel A
Although gunshot injuries to the penis occur relatively infrequently in patients with penetrating trauma, they often present dilemmas of subsequent evaluation and management. We review our extensive experience with gunshot wounds to the penis at a high volume urban trauma center. The urologic trauma database was retrospectively reviewed to extract and compile information from the records of 63 patients treated for gunshot wounds to the penis. Data were accumulated for a 20-year period from 1985 to 2004 with regard to findings on physical examination, diagnostic evaluation, associated injuries, management, and outcome. We detail our technique of penile exploration and artificial erection in the management of these injuries. Penile gunshot wounds were associated with additional injuries in 53 of 63 (84%) patients. A total of 48 (76%) patients were taken to the operating room and 44 (70%) penile explorations were performed. Evaluation included retrograde urethrogram in 50 of 63 (79%) patients and was diagnostic for urethral injury in 11 of 12 (92%) cases. Primary urethral repair was performed in 8 of 12 (67%) patients with urethral injury versus 4 of 12 (33%) who underwent urinary diversion by means of suprapubic cystotomy. Evaluation and management of gunshot wounds to the penis may potentially be complex. Retrograde urethrogram should be performed in all cases except the most insignificant and superficial wounds. We describe our technique of penile exploration and artificial erection, noting excellent results in patients for whom follow-up is available. Additional studies are needed to prospectively evaluate techniques for management of gunshot urethral injuries.
Djenić, Nebojša; Višnjić, Milan; Dragović, Saša; Bojanić, Vladmila; Bojanić, Zoran; Djurdjević, Dragan; Djindjić, Boris; Kostov, Miloš
Gunshot wounds caused by the automatic rifle M70AB2 (AK-47) 7.62 mm, after the primary surgical management, were closed with delayed primary suture during the next four to seven days. This period coincides with the fibroblastic phase of wound healing. Fibrin glue is used as a local hemostatic and as a matrix for the local dosed release of antibiotics. Antibiotics addition to fibrin glue resulted in continuous diffusion into the surrounding next 4 to 7 days. The aim of this study was to create the preconditions for gunshot wounds closing without complications by the application of fibrin glue with antibiotics 24 h after primary surgical treatment. A total of 14 pigs were wounded in the gluteofemoral region by the bullet M67, initial velocity of 720 m/s. All wounded animals were surgically treated according to the principles of the war-surgery doctrine. Seven wounds were closed with primary delayed suture four days after the primary surgical treatment (traditional approach). Fibrin glue with antibiotics was introduced in seven wounds during the primary surgical treatment and primary delayed suture was done after 24 h. The macroscopic appearance and the clinical assessment of the wound were done during the primary surgical treatment and during its revision after 24 h, as well as histopathological findings at the days 4 and 7 after wounding. Gunshot wounds caused by the automatic rifle M70AB2 (AK-47) 7.62 mm, and treated with fibrin glue with antibiotics after primary surgical management, were closed with primary delayed suture after 24 h. In further wound evolution there were no complications. Uncomplicated soft-tissue wounds caused by an automatic M70AB2 rifle may be closed primarily with delayed suture without the risk of developing complications if on revision, 24 h after primary surgery, there were no present necrotic tissues, hematoma, and any signs of infection when fibrin glue with antibiotics (ceftriaxone and clindamycin) was applied. The use of this method
Driessen, A; Tjardes, T; Eikermann, C; Trojan, S; Fröhlich, M; Grimaldi, G; Kosse, N
We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.
Medzon, Ron; Rothenhaus, Todd; Bono, Christopher M; Grindlinger, Gene; Rathlev, Niels K
Retrospective chart review. To determine the frequency of stable and unstable cervical spine fractures after gunshot wounds to the head or neck; to identify potential risk factor(s) for an unstable versus stable cervical spine fracture. Cervical spine fractures after gunshot wounds to the head and neck are common. Because of the nature of their injuries, patients often present with concomitant airway obstruction and large blood vessel injury that can necessitate emergent procedures. In some cases, acute treatment of these problems can be hindered by the presence of a cervical collar or strict adherence to spinal precautions (i.e., patient laying supine). In such situations, information regarding the probability of a stable versus unstable cervical spine fracture would be useful in emergency treatment decision making. A search for patients with gunshot wounds to the head or neck potentially involving the cervical spine over a 13-year period was performed using a trauma registry. Individuals with cervical spine fractures were identified and their records reviewed in detail. Data collected included information about neurologic deficits, mental status, airway treatment, entrance wounds, fracture level/type, initial/definitive fracture treatment, and final disposition at hospital discharge. A total of 81 patients were identified; 19 had cervical spine fractures. There were 5 patients who were not examinable because of altered mental status (severe head trauma, hemorrhagic shock, or intoxication). All 5 patients had stable cervical spine fractures. There were 11 patients who had an acute spinal cord injury, 3 (30%) of whom underwent surgery for an unstable fracture. Of the 65 awake, alert patients without a neurologic deficit, only 3 (5%) had a fracture, none of which were unstable. Gunshot wounds to the head and neck had a high rate of concomitant cervical spine fracture. Neurologically intact patients have a lower rate of fracture than those presenting with a spinal
Fabeck, L; Hock, N; Goffin, J; Ngatchou, W
Ballistic trauma is not the prerogative of battlefields and currently extends to civil environments. Any surgeon or emergency room can be faced with such trauma whose management requires an understanding of wound ballistics. The aim of this retrospective is reviewing the management of ballistic trauma within the C.H.U. Saint-Pierre hospital over a period of ten years. Data recorded included demographics data, lesions, clinical parameters, imaging, treatment and outcome. It appears that the wounds of the members have a low mortality rate but a significant rate of complications. Patients should be managed according to the ATLS protocol and according hemodynamic stability and location of the injury, benefit from imaging. Unstable patients will be operated in emergency, stable patients will be treated according to the extent of damage and the type of fracture either conservatively or by external fixator and intramedullary centromedullary. Debridement and antibiotics are recommended as a nerve exploration if there is a peripheral paralysis. The management of trauma in our sample appear not optimal in light of the literature especially in terms of setting the vascular point of debridement, antibiotic and nerve repair resulting in significant consequences. Two management protocols according to patients' hemodynamic status are offered.
Penn-Barwell, Jowan G; Sargeant, Ian D
Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound. The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity. There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006). More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration. Crown
Tomos, Ioannis; Manali, Effrosyni D; Argentos, Stylianos; Raptakis, Thomas; Papiris, Spyros A
Gunshot tracheal injuries represent life-threatening events and usually necessitate emergent surgical intervention. We report a case of an exceptional finding of a patient with retained ballistic fragments in the soft tissues of the thorax, proximal to the right subclavian artery and the trachea, carrying silently his wounds for two decades without any medical or surgical intervention. The bullet pellet on the upper part of the trachea seen accidentally in the chest computed tomography, was also found during bronchoscopy. In short "luck's always to blame".
Huet, Nicolas, E-mail: firstname.lastname@example.org; Rodiere, Mathieu, E-mail: email@example.com; Badet, Michel, E-mail: firstname.lastname@example.org
We report the first case of endovascular covered stent implantation for the treatment of a large pulmonary artery pseudoaneurysm (PAPA) following a right thoracic gunshot wound. After resuscitation and hemodynamic stabilization, a CT angiography was performed to analyze the neck size of the PAPA and its position relative to the branches of the parent artery. Covered stent implantation with additional coil embolization was successfully performed. At the 4-year follow-up, the stents remained patent and there was neither pseudoaneurysm recurrence nor treatment-related complication.
Kozlov, V K; Akhmedov, B G; Chililov, A M
To increase an efficiency of complex treatment of patients with diaphyseal gunshot fractures of long bones by introduction of modern minimally invasive surgical techniques of internal osteosynthesis into clinical practice of civil health care and to improve the outcomes in victims. Prospective comparative clinical trial included 104 victims from the Republic of Yemen with gunshot wounds of limbs of various severity for the period 2009-2011. There were diaphyseal fractures of long bones of limbs associated with soft tissue injuries. Men were predominant (80.7%). Age ranged from 15 to 80 years (mean 38,5 ± 5,7 years). Various surgical techniques of simultaneous and staged treatment were used for gunshot fractures of long bones of limbs. Additional immune therapy was prescribed to prevent infectious complications in the most severe cases. Victims were comprehensively treated according to different staged treatment: conventional surgical treatment with external fixation devices or early primary minimally invasive functionally stable osteosynthesis with LCP/BIOS plates were applied for low-energy fractures; in case of high-energy fractures the first stage included external fixation devices deployment followed by their subsequent replacement during delayed minimally invasive osteosynthesis. The essence of improvement is pursuit to simultaneous minimally invasive surgery by using of current plates for osteosynthesis and preventive immunotherapy of immune dysfunction to eliminate infectious complications. As a result, we obtained 2-fold decrease of surgical invasiveness (r≤0,01) and hospital-stay (r≤0,01). Repeated osteosynthesis was not made. Also 4-fold and 40-fold reduction of infectious and noninfectious complications was observed. This management was accompanied by reduced rehabilitation tine and significantly improved quality of life. Improved technique and algorithm of complex treatment of diaphyseal gunshot fractures of long bones of limbs were described
Maiden, Nicholas R; Hiss, Jehuda; Gips, Hadas; Hocherman, Gil; Levin, Nadav; Kosachevsky, Olga; Vinokurov, Asya; Zelkowicz, Avraham; Byard, Roger W
De-identified wound data from 197 homicidal gunshot postmortems were obtained between 2000 and 2008. Forensic ballistics data were only available for cases between 2004 and 2008. Males represent 91% of gunshot victims and were struck in the thorax/abdomen with an average of 2.3 bullets. The type of firearms involved were semi-automatic pistols in the predominant caliber 9-mm Luger and assault rifles in caliber 5.56 × 45 mm and caliber 7.62 × 39 mm Soviet, using full metal jacket bullets. The majority of shootings occurred at ranges of 1 m or greater. The most common bullet path was front to back in 66% of cases. Entry wounds occurred more often on the left side of the thorax, abdomen, and back. The most common critical organs/tissues to sustain bullet trauma in descending order were as follows: heart, lungs, liver, aorta, spleen, kidneys, and vena cava. Ribs were struck by most bullets that entered the thorax. © 2015 American Academy of Forensic Sciences.
Chen, Bi; Ding, Guo-bin; Tang, Chao-wu
To investigate the therapeutic effect of nanometer silver impregnated dressing on gunshot wounds after being immersed in brine and tapwater in rabbits. Rabbits were randomly divided into two groups after receiving gunshot wounds in both lower limbs. In group 1, the wounded limbs on the experimental side were immersed in brine for 5 h; in group 2, the wounded limbs on experimental side were immersed in tapwater for 5 h. All the wounds were treated with nanometer silver impregnated dressing on the experimental sides, while those of the control sides were treated with vaseline dressing. Biopsy was done after 30 min and 1, 2, 3, 4, 5 h, respectively. In group 1, the onset of inflammation around the wounds of the experimental sides was delayed, the inflammatory response was less serious, and the wounds were dry with less exudation compared to the controls. The mean healing time of the entry wounds on experimental and control sides was (29.4 +/- 6.6) d and (36.3 +/- 6.0) d (P < 0.01), respectively, and that of the exit wounds on experimental and control sides was (20.1 +/- 6.0) d and (27.3 +/- 5.7) d (P < 0.01), respectively. In group 2, only one of the experimental wounds showed mild inflammation, while all of the control wounds showed serious inflammation with much exudation. The mean healing time of the entry wounds on experimentsides was (13.0 +/- 1.52) d, while that on control sides was (16.0 +/- 3.10) d (P < 0.01). The mean healing time of exit wounds on experimental sides was (11.0 +/- 2.75) d, and those of the control sides was (15.6 +/- 2.85) d (P < 0.01). The nanometer silver impregnated dressing can control infection and accelerate healing in gunshot wounds in rabbits.
Weinstein, Joseph; Putney, Emily; Egol, Kenneth
Controversy exists among the orthopedic community regarding the treatment of gunshot injuries. No consistent treatment algorithm exists for treatment of low energy gunshot wound (GSW) trauma. The purpose of this study was to critically examine the wound contamination following low velocity GSW based upon bullet caliber and clothing fiber type found within the injury track. Four types of handguns were fired at ballistic gel from a 10-foot distance. Various clothing materials were applied (denim, cotton, polyester, and wool) circumferentially around the tissue agar in a loose manor. A total of 32 specimens were examined. Each caliber handgun was fired a minimum of 5 times into a gel. Regardless of bullet caliber there was gross contamination of the entire bullet track in 100% of specimens in all scenarios and for all fiber types. Furthermore, as would be expected, the degree of contamination appeared to increase as the size of the bullet increased. Low velocity GSWs result in significant contamination regardless of bullet caliber and jacket type. Based upon our results further investigation of low velocity GSW tracks is warranted. Further clinical investigation should focus on the degree to which debridement should be undertaken.
Szleszkowski, Łukasz; Thannhäuser, Agata; Szwagrzyk, Krzysztof; Kawecki, Jerzy; Jurek, Tomasz
This study presents the results of the analysis of the remains of 23 executed male individuals aged between 21 and 63 years, recovered from Osobowicki Cemetery in Wroclaw (Poland), field 83B, in 2012. In 1948 and 1949, prisoners sentenced to death by firing squad--most of them associated with the post-war anti-communist underground independence movement in Poland--were buried there. The aim of the study was to analyse fatal wounds and the method of execution, and to compare the results to data from archival documents. The results were also compared with studies concerning executions during a later period, i.e. 1949-1954. The research on the method of execution during this period of history carried out during the exhumations in Osobowicki Cemetery was the first conducted on such a scale in Poland. Forensic analysis revealed a wide variety of gunshot wounds inflicted during executions, revealing both gunshots to the head, especially single shots to the back of the head, and cases corresponding to the use of a firing squad, probably equipped with machine guns. The results of the research indicate that capital punishment by shooting was carried out in ways both similar to those the specified in the regulations and completely different. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Viel, Guido; Gehl, Axel; Sperhake, Jan P
When two fracture lines of a solid surface (ice, glass, eggshell, etc.) intersect, it is always possible to tell which one has been made first. Indeed pre-existing damage of the surface arrests all the fracture lines produced by subsequent impacts. This well-known principle (established by Puppe in 1903) has been largely used in glass fracture analysis, but can be applied also to the examination of skull fractures. It can help sequencing blunt force or gunshot injuries determining the direction of fire and differentiating entrance from exit wounds in the absence of specific distinguishing features (i.e., internal/external beveling of the skull or overlying skin indicators). In this context, we report the case of a 76-year-old man who shot himself in the mouth with a Walther PPK 7.65 handgun and highlight the utility of the application of both Puppe's Rule and Multislice Computed Tomography (MSCT) in the examination of gunshot wounds to the skull.
Hootman, J; Annest, J; Mercy, J; Ryan, G; Hargarten, S
Objective—To characterize non-fatal firearm related injuries other than gunshot wounds (non-GSWs) treated in hospital emergency departments in the United States that occur during routine gun handling and recreational use as well as violence related use of a firearm. Methods—Cases were identified through the National Electronic Injury Surveillance System (NEISS). During the study period, 1 January 1993 through 31 December 1996, NEISS consisted of a nationally representative sample of 91 hospitals in the United States having at least six beds and providing 24 hour emergency services. Results—An estimated 65 374, or an average of 16 300 per year, non-fatal, non-GSWs were treated in American hospital emergency departments during the four year study period. Fifty seven per cent of all the non-fatal, non-GSWs were violence related, most of which involved being struck by a firearm. The majority of unintentional non-fatal, non-GSWs were self inflicted and occurred during routine gun handling or recreational use of a firearm; 43% of these injuries resulted from gun recoils. Conclusions—Non-fatal, non-GSWs make a notable contribution to the public health burden of firearm related injuries. Firearm related injury prevention programs should focus on not only the reduction of gunshot wounds but also the reduction of unintentional and violence related non-GSWs. PMID:11144625
Giraudo, Chiara; Fais, Paolo; Pelletti, Guido; Viero, Alessia; Miotto, Diego; Boscolo-Berto, Rafael; Viel, Guido; Montisci, Massimo; Cecchetto, Giovanni; Ferrara, Santo Davide
The analysis of gunshot residue (GSR) on the clothing and the underlying skin of the victim may play an important role in the reconstruction of the shooting incident. The aim of the present study was to test micro-computed tomography (micro-CT) for the analysis of firearm wounds experimentally produced on human skin covered by textiles. Firing trials were performed on 60 sections of human calves enveloped by a single layer of fabric (cotton or jeans or leather or nylon) and 15 controls consisting of bare calves. Experimental firings were conducted in a ballistic laboratory at three different muzzle-to-target distances (5, 15, and 30 cm), using a .32 ACP pistol (Beretta Mod. 81) loaded with full-jacketed bullets coming from the same production lot (7.65 × 17 mm, Browning SR). The visual inspection revealed the classic pattern of GSR distribution on the fabrics and the skin of control samples, while only a dark ring around the entrance lesion was identified on the skin beneath the fabrics. Micro-CT analysis showed the presence of radiopaque material on all entrance wounds, with a statistically significant difference between cases and controls. No differences were found among specimens covered by fabrics, with regard to the firing distance and the type of clothing. No GSR-like deposits were detected in exit wounds. Our results suggest that micro-CT analysis may be a useful screening tool for differentiating entry from exit gunshot wounds when the covering textiles are contaminated, damaged, or missing.
Maraqa, Tareq I; Shin, Ji-Sun J; Diallo, Ismael; Sachwani-Daswani, Gul R; Mercer, Leo C
Obturator artery injury (OAI) from pelvic gunshot wounds (GSW) is a rarely reported condition. Hemorrhages from pelvic trauma (PT) are mostly venous. Arterial hemorrhages represent about 10-20% of PTs. When arterial hemorrhages from PT occur, they are a severe and deadly complication often causing significant hemodynamic instability and eventual shock. A 23-year-old male presented to our emergency service via a private vehicle with multiple gunshot wounds to both thighs and to the lower back, resulted in rectal and obturator artery (OA) injuries. The patient underwent a successful coil-embolization of the right OA. Given the density of structures within the pelvis, patients who sustain gunshot wounds to the pelvic region are at high risk for injury to the small bowel, sigmoid colon, rectum, bladder, and/or vascular structures. While bleeding is the major cause of early mortality in PT, rectal injuries carry the highest mortality due to visceral injuries. A high clinical index of suspicion is needed to diagnose an iliac artery injury or injury to its branches. Prompt computed tomographic angiogram (CTA) and embolization of the OA is the best method to control and stop the bleeding and improve the mortality outcome. Clinicians caring for patients presenting with pelvic gunshot wounds should pay attention to the delayed presentation of internal hemorrhage from the OAs. A multidisciplinary team approach is crucial in the successful management of penetrating injuries to the obturator artery.
Meijering, V M; Hattam, A T
Gunshot wounds (GSW) to the chest are common presentations to trauma centres both in South Africa and internationally. The clinical management and outcome of GSW to the chest are significantly altered by missile trajectory and the associated anatomical structures injured making them challenging injuries to treat. Currently, the management of GSW chest is based on scant evidence and treatment is typically according to algorithms based largely on the anecdotal experience of high volume institutions and experienced clinicians. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated for the year 2015 for all patients with GSW chest. The data was then analysed using descriptive statistics. A total of 141 patients with GSW to the chest were admitted to the Trauma Centre with a median age of 26 years . More than half of the patients, 53.2% (n = 75), sustained an isolated GSW to the chest. Overall, 29.1% (n = 41) patients sustained thoraco-abdominal injury, which accounts for a significant higher number of emergency surgeries compared to patients with non thoraco-abdominal injury (54% vs 15%, p = < 0.01). 9.2% (n = 13) of all patients required an emergency thoracotomy or emergency chest surgery (resp. 3.5% and 5.7%) of which 5 patients survived. Overall mortality was 7.1% (n = 10) of which 5 patients died from a thoracic cause. Civilian GSW to the chest are common injuries seen in Cape Town, often with concomitant injuries leading to increased morbidity. Significantly more emergency surgeries were done in patients with thoraco-abdominal injury. Overall few patients needed chest-related emergency operative intervention (9.2%) with a survival rate of 38.5%. Overall mortality of patients with GSW chest who reached the hospital was 7.1% of whom 50% died from a thoracic cause.
Gröbe, A; Klatt, J; Heiland, M; Schmelzle, R; Pohlenz, P
Gunshot wounds of the viscerocranium are a rare occurrence during times of peace in Europe. The removal of projectiles is recommended; in some cases, however, this is controversial. The material properties of projectiles and destruction of anatomical landmarks make it difficult to determine their precise location. Therefore, navigation systems and cone-beam computed tomography (CT) provide the surgeon with continuous intraoperative orientation in real-time. The aim of this study was to report our experiences for image-guided removal of projectiles, the use of cone-beam computed tomography and the resulting intra- and postoperative complications. We investigated 50 patients with gunshot wounds of the facial skeleton retrospectively, 32 had image-guided surgical removal of projectiles in the oral and maxillofacial region, 18 had surgical removal of projectiles without navigation assistance and in 28 cases we used cone-beam CT in the case of dislocated projectiles and fractured bones. There was a significant correlation (p = 0.0136) between the navigated versus not navigated surgery and complication rate (8 vs. 32%, p = 0.0132) including major bleeding, soft tissue infections and nerve damage. Furthermore, we could reduce operating time while using a navigation system and cone-beam CT (p = 0.038). A high tendency between operating time and navigated surgery (p = 0.1103) was found. In conclusion, there is a significant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system. In all these cases we were able to present reduced operating time. Cone-beam CT plays a key role as a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively.
Johnson, J; Markiewicz, M R; Bell, R B; Potter, B E; Dierks, E J
The purpose of this study was to evaluate whether orientation of a firearm predicts survival, and to identify risk factors associated with fatality in subjects with self-inflicted craniomaxillofacial gunshot wounds. A retrospective cohort study design was used. The primary predictor variable was orientation of the weapon, defined as in the coronal (lateral) or sagittal (anterior-posterior) trajectory pattern. The primary outcome variable was death for subjects on arrival or during their hospital stay. Other covariates measured include demographic, firearm-related, and psychosocial variables. Risk factors for fatality were identified using multivariate logistic regression. Of the 92 subjects that met study inclusion criteria, 47 (67.2) held the firearm in the coronal position. In the full multivariate model, coronal gun orientation (OR=7.7, 95% CI: 2.0, 30.1, p=0.003) and the absence of a psychiatric diagnosis were associated with an increased risk of fatality (OR=0.1, 95% CI: 0.04, 0.5, p=0.002). Coronal firearm orientation was associated with an increased risk of fatality following self-inflicted craniomaxillofacial gunshot injuries. A patient with a documented psychiatric disorder was not found to be more likely to succumb to this type of injury. Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Zsoldos, C M; Basamania, C J; Bal, G K
Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as 'suicide shoulder' caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.
Hafertepen, Stephen C; Davis, James W; Townsend, Ricard N; Sue, Lawrence P; Kaups, Krista L; Cagle, Kathleen M
Poorly designed experiments and popular media have led to multiple myths about wound ballistics. Some of these myths have been incorporated into the trauma literature as fact and are included in Advanced Trauma Life Support (ATLS). We hypothesized that these erroneous beliefs would be prevalent, even among those providing care for patients with gunshot wounds (GSWs), but could be addressed through education. ATLS course content was reviewed. Several myths involving wound ballistics were identified. Clinically relevant myths were chosen including wounding mechanism, lead poisoning, debridement, and antibiotic use. Subsequently, surgery and emergency medicine services at three different trauma centers were studied. All three sites were busy, urban trauma centers with a significant amount of penetrating trauma. A pre-test was administered prior to a lecture on wound ballistics followed by a post-test. Pre- and post-test scores were compared and correlated with demographic data including ATLS course completion, firearm/ballistics experience, and years of post-graduate medical experience (PGME). One-hundred and fifteen clinicians participated in the study. A mean pre-test score of 34 % improved to 78 % on the post-test with associated improvements in all areas of knowledge (p < 0.001). Years of PGME correlated with higher pre-test score (p = 0.021); however, ATLS status did not (p = 0.774). Erroneous beliefs involving wound ballistics are prevalent even among clinicians who frequently treat victims of GSWs and could lead to inappropriate treatment. Focused education markedly improved knowledge. The ATLS course and manual promulgate some of these myths and should be revised.
Kralovec, Michael E; Houdek, Matthew T; Martin, John R; Morrey, Mark E; Cross, William W
A 42-year-old man sustained a gunshot wound to the foot, which caused multiple fractures of the tarsal bones. Over the course of 6 hours, he became obtunded and began to experience respiratory compromise and neurologic symptoms. On magnetic resonance imaging, he was found to have innumerable tiny infarcts consistent with fat embolism syndrome. He was placed in a spanning external fixator. The patient remained in a coma for 6 weeks after injury but gradually regained function. Fat embolism syndrome is classically described as resulting from injury to the diaphysis of a long bone, but it can occur secondary to trauma of the foot. Neurovascular status must be continually evaluated in the setting of any bony trauma, and index of suspicion should remain high when neurologic deficits are encountered.
Sinnott, J D; Morris, G; Medland, P J; Porter, K
A case is presented in which a high velocity rifle (shotgun) was fired into the inferior part of a patient's face in an attempted suicide causing widespread trauma to the inferior and left side of the patient's face. He presented to his general practitioner where an ambulance was called. The patient is followed from prehospital care (air ambulance) to resuscitation in accident and emergency and through the first stages of reconstructive surgery. The article focuses on the multidisciplinary approach to the patient's prehospital care and initial resuscitation at a major trauma centre. CT reconstruction images of the patient's skull allow visualisation of the extent of bone damage at presentation. Medical photography allows visualisation of the extent of the initial damage and shows how reconstructive surgery was undertaken early and in progressive stages. A literature review was performed allowing discussion of the current evidence and best practice in the management of facial gunshot wounds. PMID:26823355
Sinnott, J D; Morris, G; Medland, P J; Porter, K
A case is presented in which a high velocity rifle (shotgun) was fired into the inferior part of a patient's face in an attempted suicide causing widespread trauma to the inferior and left side of the patient's face. He presented to his general practitioner where an ambulance was called. The patient is followed from prehospital care (air ambulance) to resuscitation in accident and emergency and through the first stages of reconstructive surgery. The article focuses on the multidisciplinary approach to the patient's prehospital care and initial resuscitation at a major trauma centre. CT reconstruction images of the patient's skull allow visualisation of the extent of bone damage at presentation. Medical photography allows visualisation of the extent of the initial damage and shows how reconstructive surgery was undertaken early and in progressive stages. A literature review was performed allowing discussion of the current evidence and best practice in the management of facial gunshot wounds. 2016 BMJ Publishing Group Ltd.
Fraser, Charles D; Goeddel, Lee; Patel, Nishant D; Azoury, Said C; Grimm, Joshua C; Sheinberg, Rosanne B; Sciortino, Christopher M
Missile embolus to the heart, although uncommon, is one of the most challenging scenarios in trauma. We describe a 36-year-old man who presented with a gunshot wound to the left chest and a chest x-ray revealing a foreign body in the mediastinum. A median sternotomy was performed and an injury to the left ventricle was identified. After intraoperative echocardiography and fluoroscopy confirmed a foreign body in the aortic root, cardiopulmonary bypass was implemented. A bullet was retrieved from the noncoronary sinus of the aortic valve. Injuries to the anterior leaflet of the mitral valve and left ventricle were repaired. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Trahan, Jayme; Serban, Daniel; Tender, Gabriel C
Gunshot wounds (GSW) to the spine represent a major health concern within today's society. Our study assessed the epidemiologic characteristics of patients with GSW to the spine treated in New Orleans. A retrospective chart review was performed from January 2007 through November 2011 on all the patients who were seen in the emergency room and diagnosed with a gunshot wound to the spine. Epidemiologic factors, as well as the results of admission toxicology screening, were noted. Outcome analysis was performed on patients undergoing conservative versus operative management for their injuries. Clinical outcomes were assessed using the ASIA classification system. Complications related to initial injury, neurosurgical procedures, and hospital stay were noted. A total of 147 patients were enrolled. Of those diagnosed with a GSW to the spine, 88 (59.8%) received an admission toxicology screen. Seventy-three (83%) patients out of those tested had a positive screen, with the most common substances detected being cannabis, cocaine, and alcohol. In regards to management, 127 (87%) patients were treated conservatively and only one (0.7%) patient improved clinically from ASIA D to E. Of the 20 patients who underwent surgery, one (5%) patient had clinical improvement post-operatively from ASIA C to D. This study evaluates the largest number of patients with GSW to the spine per year treated in a single centre, illustrating the violent nature of New Orleans. In this urban population, there was a clear correlation between drug use and suffering a GSW to the spine. Surgical intervention was seldom indicated in these patients and was predominately used for fixation of unstable fractures and decompression of compressive injuries, particularly below T11. Minimally invasive techniques were used successfully at our institution to minimize the risk of post-operative CSF leak. Copyright © 2013 Elsevier Ltd. All rights reserved.
Germerott, Tanja; Preiss, Ulrich S; Ross, Steffen G; Thali, Michael J; Flach, Patricia M
We sought to determine the effect of postmortem ventilation in combination with a suction pump in cases showing penetrating trauma to the chest with haemo- and/or pneumothorax, for better evaluation of the lungs in postmortem computed tomography (PMCT). The study included 6 subjects (1 female, 5 male; age 32-67years) with a penetrating gunshot or stab wound to the chest and consecutive pneumo- and/or haemothorax. The pneumo- and haemothorax were evacuated by a suction pump, and postmortem ventilation was applied using a home care ventilator. PMCT images with and without postmortem ventilation were compared, as well as the autopsy results. In three cases haemo- and pneumothorax was clearly reduced. Postmortem ventilation led to distinct re-expansion of the lungs in two cases, and to re-expansion of single lung lobes in two cases with shotgun injuries. No visible effect was seen in the remaining two cases, because of extensive destruction of lung tissue and blood aspiration. In two cases the injuries sustained in the individual lung lobes were successfully located during postmortem ventilation. The bullet channel was apparent in one case; in another case, injury of the pericardium became visible by generating pneumopericardium. The present method is capable of improving evaluation of the postmortem lung in the presence of single stab or gunshot wounds and if there is no severe destruction of the respiratory system and aspiration. Forensic autopsy should still be considered as the gold standard, although in some cases the present method might be helpful, especially where no autopsy is required. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Learch, T J; Hansch, L P; Ralls, P W
The purposes of this study were to characterize sonographic findings in patients with scrotal injuries caused by gunshot wounds and to determine if sonography can be used to detect and differentiate various scrotal abnormalities. If patients are managed conservatively, less serious injuries (hydroceles, hematoceles, and scrotal hematomas) must be separated from those requiring urgent surgical repair (testicular rupture). Sonograms obtained in 19 patients to evaluate gunshot wounds to the scrotum were studied for evidence of testicular rupture, extratesticular soft-tissue abnormalities, and the presence and location of foreign bodies. The results were compared with clinical (19 patients) and surgical (six patients) findings. Retrospective review of the sonograms showed normal testicles without evidence of rupture in 11 patients, eight of whom had scrotal hematomas, hydroceles, or hematoceles. Nine of the 11 patients were treated conservatively, and their symptoms resolved. In one of the other two patients, a prominent vessel was initially mistaken for a fracture plane; the testicle was found to be intact at surgery. The other patient was taken to surgery to remove a bullet in the peritesticular soft tissues; surgery demonstrated intact, viable testicles bilaterally, but both epididymides had through-and-through tracts from the bullet. Two patients had sonolucent tracks from missile pathways in otherwise normal appearing testicles. Testicular rupture was sonographically detected in six patients. Sonograms in all patients with surgically confirmed testicular rupture showed heterogeneous echogenicity and loss of smooth oval contour. In one patient, the sonogram showed a fracture plane. Sonograms showed foreign bodies in five patients and localized them to the testicular parenchyma (one patient) and to extratesticular soft tissues (four patients). Sonography can distinguish various scrotal abnormalities caused by ballistic trauma, information that can be useful to the
Helling, T S; McNabney, W K; Whittaker, C K; Schultz, C C; Watkins, M
Surgical management of gunshot wounds of the head has remained a controversial issue in the care of civilian patients. In an attempt to determine who might benefit from aggressive surgical intervention, we examined 89 patients over a 3-year period who had suffered cranial gunshot wounds and had at least one computed tomographic scan of the head after admission. Patients were divided into those receiving early (less than 24 hours) surgical intervention (ES, n = 27), late (greater than 24 hours) surgical intervention (LS, n = 6) or no surgical intervention (NS, n = 56). Overall mortality was 63%. Ten of 27 patients (37%) in the ES group died compared with 46 of 56 patients (82%) in the NS group (p less than 0.0001). Glasgow Coma Scale (GCS) scores in the ES group averaged 7.86 +/- 4.72 and in the NS group 5.59 +/- 4.42 (p less than 0.05). The GCS scores in the LS group (all of whom survived) were significantly higher than those of the other two groups, 12.17 +/- 4.10. The number of patients with GCS scores of 3 or 4 on admission was significantly less in the ES (41%) than in the NS group (66%, p = 0.035) and survival was better with surgery (36%) than without (3%, p = 0.007). Patients with mass lesions (clot, ventricular blood) were more often found in the ES group (17/27) than in the NS group (18/56) (p = 0.008). Patients with bihemispheric injuries fared better with surgery (7 of 14 survivors) than without (2 of 33 survivors, p = 0.0003). Only one infectious complication (brain abscess) was encountered in the LS group. No delayed intracranial complications in survivors in the NS group were seen.(ABSTRACT TRUNCATED AT 250 WORDS)
Syre, Peter; Rodriguez-Cruz, Leonardo; Desai, Rajiv; Greene, Karl A; Hurst, Robert; Schuster, James; Malhotra, Neil R; Marcotte, Paul
Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries. A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities. Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular
Jimenez, Carlos Mario; Polo, Jonathan; España, Julian Andres
To determine risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds (PCGWs) in civilian practice, in patients who underwent surgery with removal of bullet fragments, wound debridement, and watertight dural closure. An observational, analytical, prospective, cohort-type study was conducted with follow-up in a group of patients with PCGWs caused by a low-velocity projectile admitted between January 2000 and November 2010. There were 160 patients, 59 of whom were administered prophylactic antibiotics based on the decision of the treating neurosurgeon. Average follow-up time was 39 months (range, 3-92 months). Infection occurred in 40 patients (25%); 20 patients received antibiotics (20 of 59 [33.9%]), and 20 patients did not receive antibiotics (20 of 101 [19.8%]). Three variables were independent risk factors for infection: (i) persistence of parenchymal osseous or metallic fragments after surgery (P < 0.0001, relative risk [RR] 7.45); (ii) projectile trajectory through a natural cavity with contaminating flora (P = 0.03, RR 2.84); and (iii) prolonged hospitalization time (P < 0.0001, RR 3.695). Administration of prophylactic antibiotics was not associated with the incidence of intracranial infection secondary to PCGWs. Projectile trajectory through potentially contaminating cavities, persistence of intraparenchymal osseous or metallic fragments after surgery, and prolonged hospital stay were independent risk factors for intracranial infection. Copyright © 2013 Elsevier Inc. All rights reserved.
Sukumar, N; Shaharin, S; Razman, J; Jasmi, A Y
A patient who underwent emergency laparotomy for rectal prolapse developed repeated abdominal wound dehiscence and subsequently an enteric fistula. The management of abdominal wound dehiscence is discussed, specifically with regards to the Bogota bag. Use of Bogota bag has been reported worldwide but this may be the first report here.
The images of 66 gunshot entrance wounds with a defect on the back, a bullet in the body, hemorrhage along the wound track, and logical certainty that it was an entrance wound were collected from the files of a moderately busy medical examiner's office. Participants numbering 22 board-certified forensic pathologists viewed a single digital archival image of each of the 66 entrance wounds randomly mixed with 74 presumptive exit wounds to determine whether they were entrance or exit wounds. The concordance rate for correctly identifying the 66 logically known entrance wounds was 82.8% with a range from 58% to 97%. This pilot study was conducted to provide an evidence-based approach to the interpretation of the direction of gunshot wounds by reviewing pathologists with access only to archival photographs, and it is not a measure of the accuracy to distinguish entrance from exit wounds when given all of the circumstances. © 2016 American Academy of Forensic Sciences.
Simhan, Jay; Rothman, Jason; Canter, Daniel; Reyes, Jose M; Jaffe, William I; Pontari, Michel A; Doumanian, Leo R; Mydlo, Jack H
Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Penetrating trauma to the scrotum often requires operative intervention, with testicular salvage only possible when enough testicular tissue can be re-approximated in the traumatic setting. The present report represents the largest series of gunshot wound trauma to the scrotum in the literature. Further, it validates recommendations of the European Association of Urology guidelines on urological trauma that advocate operative intervention due to minimal rates of patient morbidity and the inherent limitations of scrotal ultrasonography in discerning testicular compromise. To report our 20-year experience of gunshot wounds (GSWs) to the scrotum and outline the management of this traumatic injury. We queried our institutional database for patients presenting with GSWs to the scrotum between 1985 and 2006. All patients underwent the standard trauma evaluation upon presentation, including physical examination of the external genitalia. Management was dictated by the presence or absence of a penetrating injury to the scrotum and associated traumatic injuries. Nonoperative and operative management of traumatic injury to the scrotum were used. Testicular salvage was performed when anatomically feasible. If testicular salvage was not feasible, an orchiectomy was performed. Scrotal exploration was performed in 91 (94%) patients while six (6%) patients were treated nonoperatively. Testicular injury was found in 44 (48%) patients undergoing exploration, six (7%) of whom had bilateral testicular injuries, which gave a total of 50 injured testicles. Of the injured testicles, 24 (48%) could not be salvaged and required orchiectomy, while 26 (52%) were debrided and repaired. The most common associated genitourinary (GU) injuries were to the corpora cavernosum (n= 20 [21%]) and urethra (n= 10 [10%]). Soft tissue injury of the extremities occurred in 54 patients (56
Amadasi, Alberto; Merli, Daniele; Brandone, Alberto; Cattaneo, Cristina
Soot soiling is a crucial forensic parameter around gunshot lesions. Carbonization, however, can severely alter human tissues and mimic such clues. This study aims at evaluating the survival of soot soiling even after carbonization in bone. A total of 36 bovine ribs (half fleshed and half defleshed) were shot with two types of bullet (both 9-mm; full metal-jacketed and unjacketed) with a near-contact range. With unjacketed bullets, the shot left in every case a clear, black, and roughly round soot stain around the entrance wound, whereas full metal-jacketed bullets left no signs of soot. Every specimen then underwent calcination in an oven at 800°C. The analysis of the charred samples clearly showed the survival of the soot soiling in both fleshed and bony samples, with a clear correspondence with the former position, but with a different color (yellow). Thus, soot soiling may survive, although with a different color, even after charring. © 2013 American Academy of Forensic Sciences.
Turco, Lauren; Cornell, David L; Phillips, Bradley
Head injuries that cross midline structures of the brain are bihemispheric. Other terms have been used to describe such injuries, but bihemispheric is the most accurate and should be standard nomenclature. Bihemispheric head injuries are associated with greater mortality and morbidity than other penetrating traumatic brain injuries (TBIs). Currently, there is a tendency to manage severe gunshot wounds (GSWs) to the head nonoperatively, despite reports of improved outcome in military patients treated aggressively. Thus, controversy exists in the management of civilian TBI. PubMed was searched for query terms, and PRISMA guidelines were used. Studies were selected by relevance and inclusion of data regarding etiology, diagnosis, and management of bihemispheric TBI. Case reports, studies not in English, and records lacking information on mechanism or bihemispheric injuries were excluded. Thirteen studies were included and most contained level IV evidence. The mean mortality rate of all head GSWs was 62% in adults and 32% in children. Bihemispheric GSWs had greater mortality rates of 82% in adults and 60% in children. There was a larger proportion of self-inflicted injury in studies with greater rates of bihemispheric injuries. Bihemispheric injuries have greater mortality rates than other penetrating TBI. Violation of midline brain structures such as the diencephalon and mesencephalon, increased rate of self-inflicted wounds, and lack of a standard management algorithm may increase the lethality of these injuries. Although bihemispheric injuries historically have been considered nonsalvageable, an aggressive surgical approach has been shown to improve outcomes, particularly in the military population. Copyright © 2017 Elsevier Inc. All rights reserved.
Webster, D J; Davis, P W
In a randomized trial of wound closure in 512 abdominal wounds, wounds were closed with either reinforced Steristrip skin closures or interrupted silk sutures. Comparisons were made of wound pain and discomfort, wound infection, discharge, redness, width, and skin reaction. The causes of peeling of the tapes were assessed. The results showed that tapes were significantly more comfortable and that patients preferred them to sutures (P less than 0.01), but wide scars occurred more often. There was no difference in rates of wound infection and no case of allergy to the tapes was seen. Closure of abdominal wounds by these tapes is a satisfactory procedure that could be used more extensively. PMID:1100188
Madsen, A S; Laing, G L; Bruce, J L; Clarke, D L
Introduction The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI). Methods A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications. Results There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a 'significant cervical injury' was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients. Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%). Conclusions Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be managed
Madsen, AS; Laing, GL; Bruce, JL
Introduction The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI). Methods A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications. Results There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a ‘significant cervical injury’ was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients. Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%). Conclusions Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be
Zebib, Laura; Stoler, Justin; Zakrison, Tanya L
We evaluated correlates of gunshot wound (GSW) injuries in Miami-Dade County, Florida. Firearm-related injury has previously been linked to socio- and geo-demographic indicators such as occupation, income, neighborhood and race in other metropolitan areas, but remains understudied in Miami. We reviewed 4,547 cases from a Level I trauma center's patient registry involving an intentional firearm-related injury occurring from 2002 to 2012. During this eleven-year study period, this trauma center was the only one in Miami-Dade County, and thus representative of countywide injuries. The crude morbidity rate of GSW injury over the 11-year period was 15 per 100,000 persons with a crude mortality rate of 0.27 per 100,000 persons. The case fatality rate of injured patients was 15.4%. Both morbidity and mortality increased modestly over the 11-year study period. The total number of GSW patients rose annually during the study period and patients were disproportionately young, black males, though we observed higher severity of injury in white populations. Geo-demographic analysis revealed that both GSW incident locations and patient home addresses are spatially clustered in predominantly poor, black neighborhoods near downtown Miami, and that these patterns persisted throughout the study period. Using spatial regression, we observed that census tract-level GSW incidence rates (coded by home address) were associated with a census tract's proportion of black residents (P < .001), single-parent households (P < .001), and median age (P < .001) (R 2 = .42). These findings represent the first representative geo-demographic analysis of GSW injuries in Miami-Dade County, and offer evidence to support urgent, targeted community engagement and prevention strategies to reduce local firearm violence.
Kiwanuka, Harriet; Aycart, Mario A; Gitlin, David F; Devine, Elaine; Perry, Bridget J; Win, Thet-Su; Bueno, Ericka M; Alhefzi, Muayyad; Krezdorn, Nicco; Pomahac, Bohdan
Facial self-inflicted gunshot wounds (SIGSWs) cause a devastating midfacial defect and pose a challenging problem to the reconstructive surgeon. Face transplantation (FT) has the potential for near-normal restoration in otherwise non-reconstructible defects. Two out of 7 FT recipients at Brigham and Women's Hospital (BWH) sustained SIGSWs. In this study, we illustrate the role of FT in the management of SIGSWs through an aesthetic, functional, and psychosocial examination of outcomes. We performed a retrospective analysis of individuals with SIGSWs who were screened at BWH between 2008 and 2015. We then collected data of the injuries, modes of conventional reconstruction (CR), and deficits. For the FT recipients, we critically reviewed the psychosocial screening process and post-transplantation aesthetic, functional, and psychosocial outcomes. A total of six individuals post-SIGSWs were screened for FT. All of them had undergone CR, with five receiving loco-regional flaps and free tissue transfers, and one undergoing serial debridement and primary soft-tissue repair. Following CR, all suffered from residual functional and aesthetic deficits. Two underwent partial FT and one is currently undergoing FT screening. We describe the pre-transplant psychosocial screening process and the aesthetic, functional, and psychosocial outcomes of the SIGSW FT recipients. We examined the facial SIGSW injury, outcomes of CR, and the mechanism of FT to offer a potential solution to the shortcomings of CR. More importantly, we highlight the critical nature of the psychosocial component of the multidisciplinary evaluation given the history of mental illness and suicidal behavior in this subset of patients. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Zafar, Syed Nabeel; Haider, Adil H; Stevens, Kent A; Ray-Mazumder, Nik; Kisat, Mehreen T; Schneider, Eric B; Chi, Albert; Galvagno, Samuel M; Cornwell, Edward E; Efron, David T; Haut, Elliott R
Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. 74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35). Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question. Copyright © 2014 Elsevier Ltd. All rights reserved.
Slavin, Justin; Beaty, Narlin; Raghavan, Prashant; Sansur, Charles; Aarabi, Bizhan
Patients presenting with gunshot wounds (GSWs) to the neck are difficult to assess because of their injuries are often severe and they are incompletely evaluated by computed tomography (CT) alone. Our institution treats hundreds of patients with GSWs each year and we present our experience using magnetic resonance imaging (MRI) in the evaluation of cervical GSWs. From August 2000 to July 2012, all GSWs to the cervical spine treated at our institution were cataloged. Seventeen patients had 1 or more MRI studies of the cervical spine. Informed consent was obtained before MRI indicating the risks of retained metal fragments in the setting of high magnetic fields. CT scans were obtained before and after MRI to document any possible migration of metal fragments. We documented patients' neurologic examination results before and after MRI and at follow-up. Patients' age range was 18-56 years (mean 29.8 years). Eleven of 17 patients had retained metal fragments seen on CT scan, including 3 patients with fragments within the spinal canal. No patient experienced a decline in neurologic function after MRI. No migration of retained fragments was observed. Fifteen of 17 patients returned for follow-up examinations, with an average follow-up interval of 39.1 weeks (range, 1.3-202.3 weeks; median, 8 weeks). For carefully selected patients, MRI can be an effective tool in assessing GSWs to the neck and it can significantly improve the evaluation and management of this cohort. No patient in our series experienced a complication related to MRI. Copyright © 2015 Elsevier Inc. All rights reserved.
Nikolić, Slobodan; Zivković, Vladimir; Babić, Dragan; Juković, Fehim
The aim of this study was to determine the differences in the anatomical site of a gunshot entrance wound and the direction of the bullet path between right- and left-handed subjects who committed a suicide by a single gunshot injury to the head. The retrospective autopsy study was performed for a 10-year period, and it included selected cases of single suicidal gunshot head injury, committed by handguns. We considered only contact or near-contact wounds. The sample included 479 deceased, with average age 47.1 ± 19.1 years (range, 12-89 years): 432 males and 47 females, with 317 right-handed, 25 left-handed, and 137 subjects with unknown dominant hand. In our observed sample, most cases involved the right temple as the site of entrance gunshot wound (about 67%), followed by the mouth (16%), forehead (7%), left temple (6%), submental (2%), and parietal region (1%). The left temple, right temple, and forehead were the sites of the gunshot entrance wounds, which were the best predictors of the handedness of the deceased (Spearman ρ = 0.149, P = 0.006). Our study showed that the direction of the bullet intracranial path in cases of suicide was even a more potent predictor of the handedness of the deceased (Spearman ρ = 0.263, P = 0.000; Wald = 149.503, P = 0.000).
Patil, Rahul; Jaiswal, Gaurav; Gupta, Tarun Kumar
Penetrating spine injury (PSI) forms the third most common cause of spine injury, only next to road traffic accidents and fall. Gunshot wound (GSW) forms the major bulk of PSI. Due to easy availability of firearms and antisocial behavior, GSW which were predominant in military population is now increasingly seen in civilized society. Here, we present a detail case review of unique case of civilian GSW indirectly causing complete spinal cord injury due to shock wave generated by the bullet, along with its systematic management. PMID:26692690
Louwes, Thijs M; Ward, William H; Lee, Kendall H; Freedman, Brett A
The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.
Louwes, Thijs M; Ward, William H; Lee, Kendall H
The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury. PMID:25705346
Canseco Cavazos, José; Palacios-Zertuche, Jorge; Reyna-Sepúlveda, Francisco; Álvarez-Villalobos, Neri; Alatorre-López, Louisiana; Muñoz-Maldonado, Gerardo
The incidence of deaths and injuries associated with gunshot wounds deserves special attention, mainly because of its repercussions on hospital resources and the diagnosis and treatment protocols. To perform an analysis on the epidemiological factors associated with gunshot wounds. An analysis was made of multiple variables of all patients diagnosed with gunshot wounds during the period between 2005 and 2015. A total of 605 cases were found, and an additional sub-group of 314 cases was obtained for a deeper analysis. The overall mortality rate was 7.9%. The main anatomical region was the abdomen, with 44%. A total of 324 laparotomies were performed, 124 incisions of the thoracic wall, and 72 vascular examinations. In the sub-group of 314 cases, a 16.9% and 42% of laparotomies and vascular examinations, respectably, were reported without evidence of injury to internal organs. Morbidity and mortality increases when 2 or more wounds are present with multiple organ injuries, in patients with multiple transfusions, or in those transferred to the intensive care unit. The incorporation of a physical evaluation format by all the departments involved is suggested for patients that are attended with gunshot wounds, in order to obtain more epidemiological information of these injuries for further studies. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.
Khan, Muhammad Sohaib; Khan, Bilal Masood; Naz, Sumbul; Pirzada, Muhammad Taqi
Operative management of all gunshot's traumas carries a high rate of unwarranted interventions that are known to cause serious complications. Selective nonoperative management is thus being increasingly practiced which has reduced these avoidable interventions. Physical examination and computed tomography scans are most sensitive in assessing need of laparotomy. Assessment of internal injuries on the basis of an estimated bullet trajectory is often practiced but has seldom been studied. We report a case of conservative management of a thoraco abdominal gun shot patient where an estimated bullet trajectory was indicative of serious injuries. To the best of our knowledge this is the first report of a thoraco abdominal gunshot that, despite of a protracted trajectory, had no sequelae and was thus managed nonoperatively. A 30 year old male patient having height of 180 cm and weight of 70 kg (Body Mass Index 21.6) presented with complaint of a penetrating injury at left side of upper torso. The patient had no symptoms or obvious bleeding and was vitally stable. On examination a 1 cm × 1 cm entry wound at the left 3rd intercostal space in the mid clavicular line was identified. The chest and abdomen were otherwise unremarkable on examination. The chest radiograph displayed clear lung fields. The abdominal radiographs displayed a bullet in the upper left quadrant of the abdomen lateral to the spine. The bullets estimated trajectory from 3rd intercostal space and its lodgment in the abdomen lateral to the spine indicated severe visceral injury. The computed tomography scan showed that the bullet was lodged postero-medially to the left kidney. All thoracic, intra peritoneal and retroperitoneal visceral structures were identified to be normal. The patient remained clinically and vitally stable, hence was managed nonoperatively being discharged after 48 h of observation. From this case we conclude that decision for managing gun shot patients should be based on objective
Pereira, Clifford; Boyd, J Brian; Dickenson, Brian; Putnam, Brant
Gunshot wounds (GSWs) to the face are an infrequent occurrence outside of a war zone. However, when they occur, they constitute a significant reconstructive challenge. We present our 10-year experience at an urban level I trauma center to define the patterns of injury, assess the morbidity and mortality, and estimate the cost to the health care system. A retrospective review was performed on all patients admitted to Harbor-UCLA Medical Center with GSWs to the head and neck region between January 1997 and January 2007. Those who had sustained GSWs to the face requiring operative intervention were closely reviewed. Between 1997 and 2007, a total of 702 patients were admitted to the Harbor UCLA Emergency Department having sustained GSWs to the head and neck region, of which 501 patients survived. Of the survivors, 28 patients (26 male, 2 female) sustained GSWs to their face requiring operative intervention. The mean age of these patients was 28 (±8.3) years. They generally presented within a few hours of the injury, but 1 individual arrived over 24 hours later. Low-velocity single gunshots (from handguns) were predominantly involved, with facial fractures occurring in all cases. Fractures were of a localized shattering type without the major displacement of bony complexes seen in motor vehicle accidents. Most required wound debridement and fracture fixation. A few patients (14.2%) underwent free tissue transfer for reconstruction (3 fibular flaps, 1 TRAM). Tracheostomy was performed in 35.7% of patients. Mean length of hospital stay was 8.3 (±7.1) days, with 50% of cases requiring admission to the intensive care unit. Mean length of intensive care unit stay was 5.2 (±5.7) days. The average cost per patient exceeded $100,000.
Ahmed, Naveed; Whelan, Jim; Brownlee, John; Chari, Vedantum; Chung, Raphael
Penetrating abdominal wounds are traditionally explored by laparotomy. We investigated prospectively the role of laparoscopy within a defined protocol for management of penetrating abdominal wounds to determine its safety and advantages over traditional operative management. The study inclusion criteria were: stab and gun shot abdominal wounds, including junction zone injuries; stable vital signs; and absence of contraindications for laparoscopy. Diagnostic end points included detection of peritoneum or diaphragm violation, visceral injuries, and other indications for laparotomy. Systematic examination was undertaken using a multiport technique whenever the peritoneum or diaphragm had been violated. All repairs were done by open operation. A total of 40.6% of patients with penetrating trauma fulfilled study criteria (52 patients). Of these, 33% had no peritoneal penetration; 29% had no visceral injuries despite violation of peritoneum or diaphragm; 38% had visceral injuries, of which 40% (mainly liver and omentum) required no intervention. Twelve patients (23% of total) had open repairs. No missed injuries or death occurred in the study. Overall, 77% of penetrating injuries with stable vital signs avoided exploratory laparotomy. Compared with National Trauma Data Bank information for patients with the same Injury Severity Scores, hospitalization was reduced by more than 55% for the entire series. Laparoscopy for penetrating abdominal injuries in a defined set of conditions was safe and accurate, effectively eliminating nontherapeutic laparotomy and shortening hospitalization.
Background Operative management of all gunshot’s traumas carries a high rate of unwarranted interventions that are known to cause serious complications. Selective nonoperative management is thus being increasingly practiced which has reduced these avoidable interventions. Physical examination and computed tomography scans are most sensitive in assessing need of laparotomy. Assessment of internal injuries on the basis of an estimated bullet trajectory is often practiced but has seldom been studied. We report a case of conservative management of a thoraco abdominal gun shot patient where an estimated bullet trajectory was indicative of serious injuries. To the best of our knowledge this is the first report of a thoraco abdominal gunshot that, despite of a protracted trajectory, had no sequelae and was thus managed nonoperatively. Case presentation A 30 year old male patient having height of 180 cm and weight of 70 kg (Body Mass Index 21.6) presented with complaint of a penetrating injury at left side of upper torso. The patient had no symptoms or obvious bleeding and was vitally stable. On examination a 1 cm × 1 cm entry wound at the left 3rd intercostal space in the mid clavicular line was identified. The chest and abdomen were otherwise unremarkable on examination. The chest radiograph displayed clear lung fields. The abdominal radiographs displayed a bullet in the upper left quadrant of the abdomen lateral to the spine. The bullets estimated trajectory from 3rd intercostal space and its lodgment in the abdomen lateral to the spine indicated severe visceral injury. The computed tomography scan showed that the bullet was lodged postero-medially to the left kidney. All thoracic, intra peritoneal and retroperitoneal visceral structures were identified to be normal. The patient remained clinically and vitally stable, hence was managed nonoperatively being discharged after 48 h of observation. Conclusion From this case we conclude that decision for managing gun
Lauer, S A; Rizzuto, P R; Goodrich, J; Adamo, A
This article is a retrospective clinical and radiographic analysis of four patients who survived high caliber orbitocraniofacial gunshot injuries. Early multidisciplinary craniofacial reconstruction included repair of comminuted orbital fractures with multiple autogenous bone grafts and/or porous polyethylene implants, enucleation, and insertion of a hollow silicone sphere as an anophthalmic socket implant. Migration of the silicone implant occurred in one case, requiring replacement with an autogenous dermis fat graft. There were no cases of extrusion or infection. Socket motility remained limited in all cases, despite reapposition of the extraocular muscles. In two cases with autogenous bone grafts along the orbital roof, there was no radiographic evidence of graft resorption after three years. Soft tissue volume deficiency and superior sulcus deformity developed in the three cases which were followed for more than six months. Despite these limitations, all four patients are wearing comfortable ocular prostheses. The postoperative results support immediate preparation of the anophthalmic socket after craniofacial reconstruction of these injuries.
Riehl, John T; Connolly, Keith; Haidukewych, George; Koval, Ken
Many types of projectiles, including modern hollow point bullets, fragment into smaller pieces upon impact, particularly when striking bone. This study was performed to examine the effect on time to union with retained bullet material near a fracture site in cases of gunshot injury. All gunshot injuries operatively treated with internal fixation at a Level 1 Trauma Center between March 2008 and August 2011 were retrospectively reviewed. Retained bullet load near the fracture site was calculated based on percentage of material retained compared to the cortical diameter of the involved bone. Analyses were performed to assess the effect of the lead-cortical ratio and amount of comminution on time to fracture union. Thirty-two patients (34 fractures) met the inclusion criteria, with an equal number of comminuted (17) and non-comminuted fractures (17). Seventeen of 34 fractures (50%) united within 4 months, 16/34 (47%) developed a delayed union, and 1/34 (3%) developed a nonunion requiring revision surgery. Sixteen of 17 fractures (94%) that united by 4 months had a cumulative amount of bullet fragmentation retained near the fracture site of less than 20% of the cortical diameter. Nine out of 10 fractures (90%) with retained fragments near the fracture site was equal to or exceeding 20% of the cortical diameter had delayed or nonunion. Fracture comminution had no effect on time to union. The quantity of retained bullet material near the fracture site was more predictive of the rate of fracture union than was comminution. Fractures with bullet fragmentation equal to or exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union/nonunion compared to those fractures with less retained bullet material, which may indicate a local cytotoxic effect from lead on bone healing. These findings may influence decisions on timing of secondary surgeries. Level III.
Riehl, John T.; Connolly, Keith; Haidukewych, George; Koval, Ken
Background Many types of projectiles, including modern hollow point bullets, fragment into smaller pieces upon impact, particularly when striking bone. This study was performed to examine the effect on time to union with retained bullet material near a fracture site in cases of gunshot injury. Methods All gunshot injuries operatively treated with internal fixation at a Level 1 Trauma Center between March 2008 and August 2011 were retrospectively reviewed. Retained bullet load near the fracture site was calculated based on percentage of material retained compared to the cortical diameter of the involved bone. Analyses were performed to assess the effect of the lead-cortical ratio and amount of comminution on time to fracture union. Results Thirty-two patients (34 fractures) met the inclusion criteria, with an equal number of comminuted (17) and non-comminuted fractures (17). Seventeen of 34 fractures (50%) united within 4 months, 16/34 (47%) developed a delayed union, and 1/34 (3%) developed a nonunion requiring revision surgery. Sixteen of 17 fractures (94%) that united by 4 months had a cumulative amount of bullet fragmentation retained near the fracture site of less than 20% of the cortical diameter. Nine out of 10 fractures (90%) with retained fragments near the fracture site was equal to or exceeding 20% of the cortical diameter had delayed or nonunion. Fracture comminution had no effect on time to union. Conclusions The quantity of retained bullet material near the fracture site was more predictive of the rate of fracture union than was comminution. Fractures with bullet fragmentation equal to or exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union/nonunion compared to those fractures with less retained bullet material, which may indicate a local cytotoxic effect from lead on bone healing. These findings may influence decisions on timing of secondary surgeries. Level of Evidence Level III PMID:26361445
Jabrocký, Peter; Pivko, Juraj; Vondráková, Mária; Tažký, Boris
In this article we focus on the effects of so called non-lethal ammunition. We studied possible mechanism of firearm injury formation as a consequence of using firearm on the body, to present a more comprehensive material in wound ballistics. We pointed out possible actions of a projectile causes on human, respectively other animal organisms, as well as to a manner in which an injury is caused by rifles or shotguns using non-lethal ammunition with rubber projectiles. In the experiment, we have focused on macroscopic analysis of the tissue penetrated by a rubber projectile fired from a long firearm and pump-action shotgun while focusing on the anatomical-morphological analysis of entry wounds to determine the effectiveness respectively, the wounding potential of the projectile. The results of the experiment based on the macroscopic analysis of entry wounds, cavities and exit wounds, show that when a rubber projectile penetrates the body it causes loss of the tissue (i.e. the minus effect) and mechanical disruption of the tissue similar to lethal projectile. Based on the measures and ballistic computations we concluded that in specific cases, like for example in a close range hit, a penetration of vital organs can cause serious or even lethal injuries.
Fong, Eva D M; Bartlett, Adam S R; Malak, Sharif; Anderson, Iain A
Abdominal wound dehiscence is a surgical catastrophe that can be attributed to patients or technical factors. The technical properties of the monofilament sutures and knots that are commonly used in abdominal closure are poorly understood. The aim of this study was to compare the tensile strength of monofilament sutures tied with conventional knots. To do this, the knot-holding capacity of four types of knots (square, surgeons', Aberdeen and loop) were tested using three types of gauge 1 monofilament suture, namely nylon, polyglyconate and polydioxanone, using a tensiometer. We found that the knot-holding capacity of the loop knot was between twofold and threefold greater than all the other knots examined. In comparing suture types, polyglyconate had the highest knot-holding capacity for all the knots that were examined and there was no difference in the tensile strength of nylon and polyglyconate tied in a square, surgeons' or Aberdeen knot (P < 0.05). In conclusion, our findings suggest that closure of an abdominal wound would be best commenced with a loop knot, using gauge 1 polyglyconate and finished with either an Aberdeen square or surgeons' knot would be appropriate.
Donnarumma, Pasquale; Tarantino, Roberto; Gennaro, Paolo; Mitro, Valeria; Valentini, Valentino; Magliulo, Giuseppe; Delfini, Roberto
Gunshot wounds to the head (GSWH) account for the majority of penetrating brain injuries, and are the most lethal. Since they are rare in Europe, the number of neurosurgeons who have experienced this type of traumatic injury is decreasing, and fewer cases are reported in the literature. We describe a case of gunshot to the temporal bone in which the bullet penetrated the skull resulting in the facial nerve paralysis. It was excised with the transotic approach. Microsurgical anastomosis among the masseteric nerve and the facial nerve was performed. GSWH are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is very high. Survivors often have high rate of complications. When facial paralysis is present, masseteric-facial direct neurorraphy represent a good treatment.
[Criteria for the determination of the distance of a gunshot from limited-range firearms based on the morphological characteristics of the wound and the results of inductively coupled plasma mass spectrometry].
Svetlolobov, D Iu; Luzanova, I S; Demidov, I V; Zorin, Iu V; Sonis, M A; Likhachev, A S
We have developed the criteria allowing to determine the distance of a gunshot from limited-range firearms (an IZh-79-9TGM pistol with the elastic bullet cartridges) based on the morphological characteristics of the wound and the results of inductively coupled plasma mass spectrometry. The method has been developed for the quantitative determination of barium, lead, and antimony in the targets depending on the gunshot distance.
Leppäniemi, Ari K
The traditional approach to abdominal war wounds consists of triage, eche-loned care, and mandatory laparotomy for penetrating abdominal injuries, and it remains valid in modern conventional wars with well-organized evacuation and surgical services. Expectant management of abdominal casualties can be considered under difficult circumstances with a high influx of patients exhausting the available resources. This can occur in regional conflicts associated with mass movements of people and with collapsed infrastructure. While always combined with adequate fluid resuscitation, antibiotic treatment, and other supportive care, the expectant approach in patients with penetrating abdominal injuries could be indicated for asymptomatic patients with multiple fragment wounds or for patients presenting several days post-injury in good condition. The focus of surgical resources and competence should be on the majority of patients with intestinal perforation only, who need surgery to save life--but not necessarily on an urgent basis--and who have a good chance of survival. The limited availability of blood products to correct blood loss and coagulation factor deficiencies, and the lack of sophisticated monitoring of hemodynamic variables that call into question the value of a damage-control approach for the most severely injured. Even if the bleeding could be temporarily controlled, the subsequent need for adequate resuscitation before returning the patient to the operating room could be difficult to achieve and would result in incompletely resuscitated patients being reoperated while acidotic, coagulopathic, and even hypothermic. Perhaps, in mass casualty situations these patients should be recognized during triage or at least early during operation, and aggressive surgery should be replaced with adequate expectant management with sedation and analgesics.
Background Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities. Methods A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. Results Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity. With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference. Conclusion The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively. PMID:20565804
Smędra, Anna; Sidelnik, Przemysław; Goryca, Wojciech; Berent, Jarosław
The article presents a case of an 18-year-old woman wounded by a shot fired from a distance with a hunting weapon. Because the location of the entrance and exit wounds initially seemed inconsistent with the reports (both wounds were described as "large and irregular in shape") and no photographs documenting the inflicted injuries were taken, the case was referred for an opinion to the Department of Forensic Medicine in Lodz. After a review of the medical records, radiology, the victim's clothing, and performance of an experiment using the gun and ammunition, it was established that the entrance wound was located on the abdomen, and the exit wound was located on the buttock. The initial problems with recognizing the entrance and exit wounds encountered by the surgical team were caused by bullet deformation. Before hitting the body, the projectile pierced a mobile phone that was in the pocket of the woman's jacket, subsequently causing a large atypical secondary entrance wound. The experiment confirmed that, when the projectile passed through an obstacle with consequent deformation, it caused more extensive gunshot wounds, both at the entrance and at the exit, as well as more severe damage to the bones.
Background Modern high-velocity projectiles produce temporary cavities and can thus cause extensive tissue destruction along the bullet path. It is still unclear whether gelatin blocks, which are used as a well-accepted tissue simulant, allow the effects of projectiles to be adequately investigated and how these effects are influenced by caliber size. Method Barium titanate particles were distributed throughout a test chamber for an assessment of wound contamination. We fired .22-caliber Magnum bullets first into gelatin blocks and then into porcine hind limbs placed behind the chamber. Two other types of bullets (.222-caliber bullets and 6.5 × 57 mm cartridges) were then shot into porcine hind limbs. Permanent and temporary wound cavities as well as the spatial distribution of barium titanate particles in relation to the bullet path were evaluated radiologically. Results A comparison of the gelatin blocks and hind limbs showed significant differences (p < 0.05) in the mean results for all parameters. There were significant differences between the bullets of different calibers in the depth to which barium titanate particles penetrated the porcine hind limbs. Almost no particles, however, were found at a penetration depth of 10 cm or more. By contrast, gas cavities were detected along the entire bullet path. Conclusion Gelatin is only of limited value for evaluating the path of high-velocity projectiles and the contamination of wounds by exogenous particles. There is a direct relationship between the presence of gas cavities in the tissue along the bullet path and caliber size. These cavities, however, are only mildly contaminated by exogenous particles. PMID:22490236
Meizoso, Jonathan P; Ray, Juliet J; Karcutskie, Charles A; Allen, Casey J; Zakrison, Tanya L; Pust, Gerd D; Koru-Sengul, Tulay; Ginzburg, Enrique; Pizano, Louis R; Schulman, Carl I; Livingstone, Alan S; Proctor, Kenneth G; Namias, Nicholas
Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05. The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. Therapeutic study, level IV.
Meijering, V M; Hattam, A T; Navsaria, P H; Nicol, A J; Edu, S
Gunshot wounds (GSW) to the chest are common presentations to trauma centres in South Africa. The clinical management and outcome of GSW to the chest are significantly altered by missile trajectory and the associated anatomical structures injured making them challenging injuries to treat. Currently, the management of GSW chest is based on scant evidence and treatment is typically according to algorithms based largely on the anecdotal experience of high volume institutions and experienced clinicians. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated for the year 2015 for all patients with GSW chest. The data was then analysed using descriptive statistics. A total of 141 patients with GSW to the chest were admitted to the Trauma Centre with a median age of 26 years. More than half of the patients, 53. 2% (n = 75) sustained an isolated GSW to the chest. Overall, 29.1% (n = 41) patients sustained a thoracoabdominal injury, which accounts for a significant higher amount of emergency surgeries compared to patients with non thoracoabdominal injuries (54% vs 15%, p = < 0.01). 9.2% (n = 13) of all patients required an emergency thoracotomy or emergency chest surgery of which 5 patients survived. Overall mortality was 7.1% (n = 10) of which 5 patients died from a thoracic cause. Civilian GSW to the chest are common injuries seen in Cape Town, often with concomitant injuries leading to increased morbidity. Significantly more emergency surgeries were done in patients with thoracoabdominal injury. Overall few patients needed chest-related emergency operative intervention (9.2%) with a survival rate of 38.5%. Overall mortality of patients with GSW chest who reached the hospital was 7.1% of whom 50% died from a thoracic cause.
Fernandes, Rui; Lee, Jason
The reconstruction of large avulsive tissue loss in the head and neck region is one of the most difficult tasks faced by reconstructive surgeons. The advent of free tissue transfer has improved our ability to predictably reconstruct these patients. One of the most recent advances in the field of microvascular surgery is the use of perforator flaps. We have used the lateral circumflex femoral artery perforator (LCFAP) flap for reconstructions in patients who have suffered severe gunshot wounds (GSWs) to the maxillofacial area. A retrospective chart review was conducted of patients treated with a LCFAP flap in our division for large defects of the face resulting from GSWs between July 2005 and July 2006. The patient's age and gender, site and size of defect, and degree of bone and soft tissue loss were recorded. Flap survival and donor site morbidity were noted as outcomes of the reconstruction. Four patients who met the inclusion criteria were identified. The success rate for the flaps was 100%. There was no partial necrosis of the flaps. The size of the defect ranged from 20 x 10 cm to 10 x 10 cm. None of the patients had donor site complications, and all donor sites were closed primarily. Use of the LCFAP flap for the reconstruction of large defects secondary to GSWs to the face is a reliable option for the immediate reconstruction of this patient population. The lateral circumflex femoral artery perforator (LCFAP) flap is at a site not involved in the immediate resuscitation of trauma patients, thus ensuring an intact vascular system. This fact makes the LCFAP flap a reliable source for small to large soft tissues for reconstructing avulsive soft tissue losses in the head and neck.
Kong, Victor Y; Weale, Ross D; Sartorius, Benn; Bruce, John L; Laing, Grant L; Clarke, Damian L
Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
Aras, M; Altaş, M; Yilmaz, A; Serarslan, Y; Yilmaz, N; Yengil, E; Urfali, B
Toward the end of 2010, the Arab spring, the waves of revolutionary demonstrations and protests influenced also Syria, where violent clashes turned into a civil war. Hundreds of thousands of people became refugees. The use of excessive force unfortunately culminated in numerous deaths and injuries in many cities. Being the closest city to Aleppo, Damascus and Homs, the biggest cities of Syria, Antioch/Hatay has been the city where initial emergency treatments were performed. For this reason, we examined and retrospectively analyzed the medical records of the patients treated in the clinics of our hospital due to cranial gunshot wounds during the war. The medical records of 186 patients who were injured in the Syrian War and brought to, followed up and treated in the Neurosurgery Clinic of Mustafa Kemal University, Faculty of Medicine in Hatay, a Turkish city on the Syrian border, between April 2011 and June 2013. A total of 186 patients were evaluated in a period of more than 2 years. Of all 91.4% of the patients were adults (male/female: 152/18) and 8.6% of them were pediatric patients (male/female: 14/2). The average age of the patients was 31 years, with an age range of between 2 months and 67 years. According to Glasgow coma score (GCS) of the patients at the time of admission, GCS was 3 in 32 patients (17.2%), between 4 and 7 in 70 patients (37.6%), and between 8 and 15 in 84 patients (45.1%). We observed that the patients with GCS of 4-7 had a significantly lower mortality among the 56 patients treated surgically compared with the 14 patients treated medically. Cranial gunshot wounds are responsible for high mortality and morbidity. A multiplicity of factors plays a role on morbidity and mortality. These are the duration of transport, the injury pattern, the velocities of the weapons used, and the Glasgow Coma Scales of the patients at the time of admission. The authors recommend that the patients with cranial gunshot wounds who has GCS of 4-7 should be
Pollak, S; Lindermann, A
Smoothbore shotgun barrels can fire cartridges with common pellet loads as well as shotgun slugs and rubber bullets. Other than conventional shot, the cylindrical Brenneke-type rifled shotgun slugs sometimes cause perforating wounds. The shotgun ammunition for use in self-defence can have a single projectile or several rubber pellets. Where the propellant is black powder, short range shots will probably leave searing marks and intensive soot deposits. Fired at close range, rubber bullets can penetrate through the skin into the body, fired at greater distance they cause contusions. A case of homicide (repeated firing with a 12-ga. pump gun) is used to present and discuss the injury patterns and X-ray findings after impact of Brenneke-type slugs and rubber bullets as well as of "classical" shot pellets.
Feliciano, David V
Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.
García, Alberto Federico; Sánchez, Álvaro Ignacio; Gutiérrez, Álvaro José; Bayona, Juan Gabriel; Naranjo, María Paula; Lago, Sebastián; Puyana, Juan Carlos
In critically ill surgical patients undergoing abdominal negative-pressure wound therapy (NPWT), it remains uncertain whether or not intra-abdominal pressure (IAP) measurements should be obtained when NPWT is activated. We aimed to determine agreement between IAP measured with and without NPWT. In this analytic cross-sectional study, critically ill surgical adults (≥18 y) requiring abdominal NPWT for temporary abdominal closure after a damage control laparotomy were selected. Patients with urinary tract injuries or with pelvic packing were excluded. Paired IAP measures were performed in the same patient, with and without NPWT; two different operators performed the measures unaware of the other's result. Bland-Altman methods assessed the agreement between the two measures. Subgroup analyses (trauma and nontrauma) were performed. There were 198 IAP measures (99 pairs) in 38 patients. Mean IAP with and without NPWT were 8.33 (standard deviation 4.01) and 8.65 (standard deviation 4.04), respectively. Mean IAP difference was -0.323 (95% confidence interval -0.748 to 0.101), and reference range for difference was -4.579 to 3.932 (P = 0.864). From 112 IAP measures (56 pairs) in 21 trauma patients, mean IAP difference was -0.268 (95% confidence interval -0.867 to 0.331), and reference range for the difference was -4.740 to 4.204 (P = 0.427). There was no statistically significant disagreement in IAP measures. IAP could be measured with or without NPWT. In critically ill surgical patients with abdominal NPWT for temporary abdominal closure, monitoring and management of IAP either with or without NPWT is recommended. Copyright © 2018 Elsevier Inc. All rights reserved.
Reddy, Amit K; Baker, Meredith S; Sobel, Rachel K; Whelan, David A; Carter, Keith D; Allen, Richard C
Suicides and attempted suicides are major public health issues in the United States and around the world. Self-inflicted gunshot wounds (SIGSWs) are a common method of attempting suicide, the head being the most commonly injured body region; however, the literature lacks an overview of the orbital and ocular injuries as well as outcomes associated with SIGSWs. To characterize the ocular and orbital injuries and outcomes of patients presenting with SIGSWs and to examine the cost associated with these injuries. Retrospective medical record review was performed of all patients who presented to the University of Iowa Hospitals and Clinics between 2003 to 2013 with the admitting diagnosis of self-inflicted injuries via firearms. Patients with no periorbital or ocular injuries and/or those who did not survive for at least 2 months following the incident were excluded. Ocular injuries and outcomes and health care costs and reimbursements, which were generated by a financial report obtained from the hospital finance department that included data from both the hospital billing and cost accounting systems. All patients in this study (n = 18) were men with a mean age of 47.2 years. Eight patients (44.4%) displayed submental missile entry points, 7 (38.9%) displayed intraoral entry points, and 3 (16.7%) displayed pericranial entry points. Patients with pericranial entries sustained more severe ocular injuries and had poorer ocular outcomes. Seven patients (38.9%) were found at final follow-up to have visual acuity of 20/40 or better in each eye and all showed missile trajectories in the sagittal plane. The mean cost of treatment of these patients totaled $117,338 while the mean reimbursement amount was $124,388. Data regarding ocular injuries and outcomes may assist ophthalmologists in the treatment of patients with SIGSWs in the future. Many patients had extremely functional vision at final follow-ups, which highlights the importance of specialists conducting examinations
Baharestani, Mona Mylene; Gabriel, Allen
The purpose of this study was to examine the clinical outcomes of negative pressure wound therapy (NPWT) using reticulated open-cell foam (ROCF) in the adjunctive management of abdominal wounds with exposed and known infected synthetic mesh. A non randomised, retrospective review of medical records for 21 consecutive patients with infected abdominal wounds treated with NPWT was conducted. All abdominal wounds contained exposed synthetic mesh [composite, polypropylene (PP), or knitted polyglactin 910 (PG) mesh]. Demographic and bacteriological data, wound history, pre-NPWT and comparative post-NPWT, operative procedures and complications, hospital length of stay (LOS) and wound healing outcomes were all analysed. Primary endpoints measured were (1) hospital LOS prior to initiation of NPWT, (2) total time on NPWT, (3) hospital LOS from NPWT initiation to discharge and (4) wound closure status at discharge. A total of 21 patients with abdominal wounds with exposed, infected mesh were treated with NPWT. Aetiology of the wounds was ventral hernia repair (n = 11) and acute abdominal wall defect (n = 10). Prior to NPWT initiation, the mean hospital LOS for the composite, PP and PG meshes were 76 days (range: 21-171 days), 51 days (range: 32-62 days) and 19 days (range: 12-39 days), respectively. The mean hospital LOS following initiation of NPWT for wounds with exposed composite, PP and PG mesh were 28, 31 and 32 days, respectively. Eighteen of the 21 wounds (86%) reached full closure after a mean time of 26 days of NPWT and a mean hospital LOS of 30 days postinitiation of NPWT. Three wounds, all with composite mesh left in situ, did not reach full closure, although all exhibited decreased wound dimensions, granulating beds and decreased surface area exposure of mesh. During NPWT/ROCF, one hypoalbuminemic patient with exposed PP mesh developed an enterocutaneous fistula over a prior enterotomy site. This patient subsequently underwent total mesh extraction, takedown of
Gellerfors, Mikael; Linde, Joacim; Gryth, Dan
Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.
Butt, Muhammad U; Zacharias, Nikolaos; Velmahos, George C
Penetrating abdominal injuries have been traditionally managed by routine laparotomy. New understanding of trajectories, potential for organ injury, and correlation with advanced radiographic imaging has allowed a shift towards non-operative management of appropriate cases. Although a selective approach has been established for stab wounds, the management of abdominal gunshot wounds remains a matter of controversy. In this chapter we describe the rationale and methodology of selecting patients for non-operative management. We also discuss additional controversial issues, as related to antibiotic prophylaxis, management of asymptomatic thoracoabdominal injuries, and the use of colostomy vs. primary repair for colon injuries. PMID:19374761
Rosemurgy, A S; Albrink, M H; Olson, S M; Sherman, H; Albertini, J; Kramer, R; Camps, M; Reiss, A
Traditionally, stab wounds violating the abdominal wall fascia led to exploratory celiotomy that was often nontherapeutic. In an attempt to limit the number of nontherapeutic celiotomies (NTC), we devised a protocol to prospectively study stab wounds violating the anterior abdominal wall fascia. Through protocol, abdominal stab wounds were explored in stable adults. If the anterior fascia was violated, paracentesis and, if necessary, peritoneal lavage was undertaken in the absence of previous abdominal surgery. If evisceration was noted, it was reduced and the patient lavaged. Fascial penetration was noted in 72 patients. 46 patients underwent celiotomy: because of shock/peritonitis in 8 (2 NTC), fascial penetration with a history of previous celiotomy in 7 (5 NTC), positive paracentesis in 20 (5 NTC), or positive lavage in 10 (4 NTC). One patient underwent late celiotomy without ill-effect after a negative lavage because she subsequently developed fever and localized peritonitis (ice pick injury to cecum). Eleven patients had evisceration; nine underwent celiotomy. Patients with abdominal stab wounds can be selectively managed safely. More than one-third with fascial penetration, some with evisceration, avoided exploration. Only one patient underwent delayed celiotomy and did so without detriment. Nontherapeutic celiotomy rates were highest in patients with previous abdominal surgery who, thereby, could not undergo paracentesis/lavage; excluding these patients, the nontherapeutic celiotomy rate was 17% (11/65) for those with fascial penetration.
noncompressible internal hemorrhage to the tho- rax. All 4 dogs that were non-KIA dogs that incurred thoracic wounds developed tension pneumothorax and 3 of...receive needle decompression for tension pneumothorax died shortly after arriving at the VTF. An occlusive bandage was ap- plied over the thoracic...hemoglobin-based oxygen car- rier (HBOC).d Unfortunately, this dog subsequently died of unrecognized/untreated tension pneumothorax after arrival at
Shackford, Steven R; Kahl, Jessica E; Calvo, Richard Y; Kozar, Rosemary A; Haugen, Christine E; Kaups, Krista L; Willey, Marybeth; Tibbs, Brian M; Mutto, Susan M; Rizzo, Anne G; Lormel, Christy S; Shackford, Meghan C; Burlew, Clay Cothren; Moore, Ernest E; Cogbill, Thomas H; Kallies, Kara J; Haan, James M; Ward, Jeanette
Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of
Garvey, Patrick B; Martinez, Roberto A; Baumann, Donald P; Liu, Jun; Butler, Charles E
The optimal type of mesh for complex abdominal wall reconstruction has not been elucidated. We hypothesized that AWRs using acellular dermal matrix (ADM) experience low rates of surgical site occurrence (SSO) and surgical site infection, despite increasing degrees of wound contamination. We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions with ADM over a 9-year period. Outcomes of abdominal wall reconstructions were compared between patients with different CDC wound classifications. Univariate and multivariate logistic regression and Cox proportional hazard regression analyses identified potential associations and predictive/protective factors. The 359 patients had a mean follow-up of 28.3 ± 19.0 months. Reconstruction of clean wounds (n = 171) required fewer reoperations than that of combined contaminated (n = 188) wounds (2.3% vs 11.2%; p = 0.001) and trended toward experiencing fewer SSOs (19.9% vs 28.7%, p = 0.052). There were no significant differences between clean and combined contaminated cases in 30-day SSI (8.8% vs 8.0%), hernia recurrence (9.9% vs 10.1%), and mesh removal (1.2% vs 1.1%) rates. Independent predictors of SSO included body mass index ≥30 kg/m(2) (odds ratio [OR] 3.6; p < 0.001), 1 or more comorbidities (OR 2.5; p = 0.008), and defect width ≥15 cm (OR 1.8; p = 0.02). Complex abdominal wall reconstructions using ADM demonstrated similar rates of complications between the different CDC wound classifications. This is in contradistinction to published outcomes for abdominal wall reconstruction using synthetic mesh that show progressively higher complication rates with increasing degrees of contamination. These data support the use of ADM rather than synthetic mesh for complex abdominal wall reconstruction in the setting of wound contamination. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Deleyto, E; García-Ruano, A; González-López, J R
Negative pressure wound therapy with instillation (NPWTi) has been proved to be a safe and effective treatment option for abdominal wall wound dehiscence with mesh exposure. Our aim in this study is to examine whether it is also cost-effective. We performed a retrospective cohort study with 45 patients treated for postoperative abdominal wall wound dehiscence and exposed mesh: 34 were treated with conventional wound therapy (CWT) and 11 with NPWTi. We carried out a cost analysis for each treatment group using the Diagnosis-related group (DRG) system and a second evaluation using the calculated costs "per hospital stay". The differences between NPWTi and CWT were calculated with both evaluation systems. Comparative analysis was performed using the Mann-Whitney U test. Mean costs using the DRG estimation were 29,613.71€ for the CWT group and 15,093.37€ for the NPWTi group, and according to the calculated expenses "per hospital stay", 17,322.88€ for the CWT group and 15,284.22€ for the NPWTi group. NPWTi showed a reduction in the total expense of treatment, related to a reduction in episodes of hospitalization and number of surgeries required to achieve wound closure. However, differences were not statistically significant in our sample. NPWTi proves to be an efficient treatment option for abdominal wall wound dehiscence with mesh exposure, compared to CWT. More trials aimed to optimize treatment protocols will lead to an additional increase in NPWTi efficiency. In addition, to generalize our results, further studies with larger samples would be necessary.
Abstract This article uses a notorious criminal trial, that of John Donald Merrett for the murder of his mother, as a case study to explore forensic medicine’s treatment of gunshot wounding in pre-war Scotland. This topic, which has hitherto received little attention from historians, provides insight into two issues facing the discipline at this time. First, the competing attempts by prosecution and defence expert witnesses to recreate the wound in a laboratory setting, in order to determine the distance from which the shot had been fired, exposed the uncertainties surrounding the application of a well-known laboratory technique for which no fully agreed-upon protocol existed. Secondly, the case allows the examination of the working relationship of a medical expert and a gunsmith, in which disciplinary boundaries became indistinct and the wound a shared site of analysis, in a period before the separate profession of forensic science became institutionally grounded in Scotland. PMID:29713115
McCunniff, Peter T; Ramey, James S; Scott, Meredith L; Roach, Mary J; Vallier, Heather A; Moore, Timothy A; Kelly, Michael L
Surgery for patients with gunshot wound spinal cord injury (GSCI) remains controversial. Few recent studies provide standardized follow-up and detailed functional outcomes. To our knowledge, the research we present in this study is unique in that we are the first to incorporate Functional Independence Measure (FIM) scores as an outcomes measure for neurologic recovery in patients with GSCI. Patients with GSCI were divided into surgical and nonsurgical groups. Neurologic function was measured according to the American Spinal Injury Association impairment scale and defined as either complete or incomplete injury. Outcomes were then analyzed separately for complete and incomplete GSCI groups during hospitalization and rehabilitation. Baseline admissions characteristics were similar between surgical and nonsurgical groups except for a greater median injury severity score in the nonsurgical group (34 vs. 27; P = 0.02). For complete GSCI, total length of stay (LOS) was significantly longer in the surgical group (52 vs. 42 days; P = 0.04), and no difference was observed in overall FIM scores (58 vs. 54; P = 0.7). For incomplete GSCI, rehabilitation LOS was longer (35 vs. 21; P = 0.02) and a trend towards longer total LOS was observed in the surgical group (40 vs. 32; P = 0.07). No difference was observed in overall FIM scores (61 vs. 62; P = 0.9). Surgery for patients with GSCI is associated with increased LOS and is not associated with improved FIM scores for patients with either complete or incomplete spinal cord injuries. Copyright © 2017 Elsevier Inc. All rights reserved.
Akcakaya, Adem; Aydogdu, Ibrahim; Citgez, Bulent
The purpose of this experimental study is to investigate and compare the effects of prosthetic materials used for wound healing of abdominal wall hernias. A total of 60 rats were divided into five equal groups: Group I, control subjected to laparotomy; group II, abdominal wall defect 3×2 cm+polypropylene (PP) mesh; group III, abdominal wall defect 3×2 cm+PP mesh+hyaluronate and carboxymethylcellulose (H-CMC; Seprafilm®); group IV, abdominal wall defect 3×2 cm+polytetrafluoroethylene (PTFE; Composix™); and group V, abdominal wall defect 3×2 cm+polyethylene terephthalate (PET; Dacron®). A total of 14 days after the surgery, rats were sacrificed and the meshes with the surrounding tissue were extracted in block. The breaking strength of the mesh from the fascia was recorded. The healing tissue was examined with the index of histopathology and the hydroxyproline value was analyzed using the Switzer method. Both the breaking strength and histopathological index of the wound healing were significantly improved in groups II and III compared with that in groups IV and V (P<0.001). Hydroxyproline values were the highest in group I (P<0.001). There was also a statistically significant difference between groups II and IV, and group V and the other groups (P<0.001). The present findings demonstrated that PP mesh and PP mesh+H-CMC had a superior breaking strength and improved histopathologic indices compared with PTFE and PET. Furthermore, hydroxyproline values were the lowest in the PET group. In conclusion, wound healing was improved in the PP mesh group and the PP mesh+H-CMC group compared with the PTFE and PET groups according to the present study parameters. PMID:29399133
de Araújo, Gabriel Costa Serrão; Mourão, Natália Teixeira; Pinheiro, Igor Natário; Xavier, Analúcia Rampazzo; Gameiro, Vinicius Schott
Background Gunshot wounds require surgeons to decide whether to remove or leave bullet fragments in the body. Surgeons also decide how to follow up with patients who have lead fragments retained in their body. Current literature recommends to remove only intra-articular fragments without the need for a follow-up for patients with the metal retained. Therefore, this study investigates chronic lead toxicity for gunshot wounds. Methods The study was performed in the metropolitan area of Rio de Janeiro/Brazil, between 2013 and 2015. It was a case-control study that included 45 victims of gunshot lesions with metallic fragments retained for more than 6 months. The 45 controls were matched for gender, age, and race. We compared the lead blood levels and frequency of symptoms. Results The control group had average blood lead levels of 2.17 μg/dL (95% Confidence Interval [CI]; 1.71–2.63) and median 2.1 μg/dL. The case group had average values of 9.01 μg/dL (CI; 6.07–11.96) and median values of 6.5 μg/dL with p-values < = 0.001. The case group reported the following more frequently: irritancy, bad mood, headache, memory losses, daylight drowsiness, myalgia, weakness, abdominal pain, joint pain, trembling, tingling limbs. There was statistical significance for the differences of symptoms frequencies and for odds ratio between groups. Conclusions Although the mean lead levels found were lower than the current laboratory references, low levels have been associated with both rising morbidity and mortality. The WHO stated: “There is no known level of lead exposure that is considered safe”. In conclusion, this work showed that bullets retained in the body are not innocuous. There are impacts in the blood lead levels and symptoms related to it, even with few fragments, extra-articular located or existing with low blood lead levels. PMID:26509498
Dragu, Adrian; Schnürer, Stefan; Unglaub, Frank; Wolf, Maya B; Beier, Justus P; Kneser, Ulrich; Horch, Raymund E
Postbariatric plastic surgery is considered to be a high-risk procedure, which entails such frequent minor complications as postoperative seroma, bleeding and wound dehiscence. These occur with a high incidence, especially, following postbariatric abdominal dermolipectomy. In order to reduce these complication rates, a new type of dressing with wide abdominal topical negative pressure (TNP) application was applied. We performed abdominal dermolipectomy in 23 obese patients. The average body mass index was 32.8 kg/m(2), and the median age of the patients was 42.9 years. Ten patients received conventional standard dressings (control group I), whereas the other 13 patients received a wide TNP dressing including the ventral and lateral trunk (negative pressure group II). Postoperative exudate volumes were collected, tallied and documented for each group separately until all drains could be removed. The conventionally treated control group (I) showed a significantly higher postoperative secretion volume compared with the negative pressure group (II). In addition, the average time to postoperative final drain removal was significantly lower in the negative pressure group (II) compared with the control group (I). The results indicate that widely applied external TNP wound dressing on the ventral and lateral trunk following postbariatric abdominal dermolipectomy leads to a significant reduction in exudate formation, enables early drain removal and thus, decreases length of hospitalization.
Puentes, Katerina; Ribeiro, Cristina; Jardim, Patrícia; Santos, Agostinho; Magalhães, Teresa
According to Portuguese law, if a case of intimate partner violence is noticed or suspected by a professional working in public services, reporting it to the police, medico-legal services or directly to the public prosecutor is mandatory. However, in most cases, reporting does not take place, despite its vital importance in triggering the multidisciplinary intervention that will ensure the correct and timely diagnosis and protection of the victim. In the present case, the victim, a 37 year-old woman, was sexually and physically abused by her husband in their home, and was physically abused again at the victim's mother's house. The victim mentioned that her husband struck her in the head with a hammer and shot a handgun while in her mother's house. However, she denied having a gunshot wound. The couple's daughter was also slapped in the face by her father. The police took the victim to the emergency room of a central hospital to receive medical attention, while the medical examiner on duty was called to the same emergency room to perform a medico-legal evaluation in the context of the intimate partner violence reported to the police. Medico-legal assessment revealed scalp injuries that had not been detected during the first inspection by the emergency room attending physicians who had performed a neurological examination, which revealed no neurological dysfunction. A cranial computed tomography with three-dimensional reconstitution and virtual dissection, requested by the medical examiner, revealed two projectiles trapped in between the inner and the outer table of the cranium, with linear fractures only in the inner table and no brain injuries. Gynecological examination with the collection of biological evidence, also performed by the medical examiner, made it possible to identify a male DNA profile matching her husband's. The victim was subjected to neurosurgery and a follow-up, and was released one month after the traumatic event. A forensic psychological
Hinkle, J; Betz, S
If current trends for this nation continue, by the year 2003 the number of people killed by firearms will exceed the number of people killed in motor vehicle accidents. Critical care practitioners must understand the mechanism of injury associated with firearm injuries to provide optimal care. This article reviews internal, exterior, and terminal ballistics, bullet design, wound classification, and initial assessment and treatment of firearm injuries.
Bae, Sung Kyu; Kang, Seok Joo; Kim, Jin Woo; Kim, Young Hwan
Background If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect. Methods From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction. Results Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery. Conclusions Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle. PMID:23362477
Hussain, Qasim; Maleux, Geert, E-mail: email@example.com; Heye, Sam
Traumatic injury of the abdominal aorta is rare and potentially lethal (Yeh et al., J Vasc Surg 42(5):1007-1009, 2005; Chicos et al., Chirurgia (Bucur) 102(2):237-240, 2007) as it can result in major retroperitoneal hemorrhage, requiring an urgent open surgery. In case of concomitant bowel injury or other conditions of hostile abdomen, endovascular repair can be an alternative treatment. This case report deals with a 50-year-old man presenting at the emergency ward with three stab wounds: two in the abdomen and one in the chest. During explorative laparotomy, liver laceration and bowel perforation were repaired. One day later, abdominal CT-scan revealedmore » an additional retroperitoneal hematoma associated with an aortic pseudoaneurysm, located anteriorly 3 cm above the aortic bifurcation. Because of the risk of graft infection, an endovascular repair of the aortic injury using a Gore excluder stent-graft was performed. Radiological and clinical follow-up revealed a gradual shrinkage of the pseudo-aneurysm and no sign of graft infection at two years' follow-up.« less
Oosthuizen, GV; Clarke, DL
Introduction The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. Methods We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. Results Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). Conclusions The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries. PMID:26263933
Kong, V Y; Oosthuizen, G V; Clarke, D L
The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.
Hussain, Qasim; Maleux, Geert; Heye, Sam; Fourneau, Inge
Traumatic injury of the abdominal aorta is rare and potentially lethal (Yeh et al., J Vasc Surg 42(5):1007-1009, 2005; Chicos et al., Chirurgia (Bucur) 102(2):237-240, 2007) as it can result in major retroperitoneal hemorrhage, requiring an urgent open surgery. In case of concomitant bowel injury or other conditions of hostile abdomen, endovascular repair can be an alternative treatment. This case report deals with a 50-year-old man presenting at the emergency ward with three stab wounds: two in the abdomen and one in the chest. During explorative laparotomy, liver laceration and bowel perforation were repaired. One day later, abdominal CT-scan revealed an additional retroperitoneal hematoma associated with an aortic pseudoaneurysm, located anteriorly 3 cm above the aortic bifurcation. Because of the risk of graft infection, an endovascular repair of the aortic injury using a Gore excluder stent-graft was performed. Radiological and clinical follow-up revealed a gradual shrinkage of the pseudo-aneurysm and no sign of graft infection at two years' follow-up.
Gröbe, Alexander; Weber, Christoph; Schmelzle, Rainer; Heiland, Max; Klatt, Jan; Pohlenz, Philipp
Gunshot wounds are a rare occurrence during times of peace. The removal of projectiles is recommended; in some cases, however, this is a controversy. The reproduction of a projectile image can be difficult if it is not adjacent to an anatomical landmark. Therefore, navigation systems give the surgeon continuous real-time orientation intraoperatively. The aim of this study was to report our experiences for image-guided removal of projectiles and the resulting intra- and postoperative complications. We investigated 50 patients retrospectively; 32 had image-guided surgical removal of projectiles in the oral and maxillofacial region. Eighteen had surgical removal of projectiles without navigation assistance. There was a significant correlation (p = 0.0136) between the navigated surgery vs. not-navigated surgery and complication rate, including major bleeding (n = 4 vs. n = 1, 8% vs. 2%), soft tissue infections (n = 7 vs. n = 2, 14% vs. 4%), and nerval damage (n = 2 vs. n = 0, 4% vs. 0%; p = 0.038) and between the operating time and postoperative complications. A high tendency between operating time and navigated surgery (p = 0.1103) was shown. When using navigation system, we could reduce operating time. In conclusion, there is a significant correlation between reduced intra- and postoperative complications, including wound infections, nerval damage, and major bleeding, and the appropriate use of a navigation system. In all these cases, we could present reduced operating time. Cone-beam computed tomography plays an important role in detecting projectiles or metallic foreign bodies intraoperatively.
Buszewska-Forajta, M; Siluk, D; Daghir-Wojtkowiak, E; Sejda, A; Staśkowiak, D; Biernat, W; Kaliszan, R
Grasshopper, belonging to Chorthippus sp., is a widespread insect inhabiting Polish territory. According to folk knowledge and folk tales, the grasshopper abdominal secretion was used by villagers of Central and South-West Poland as a natural drug accelerating the wound healing process. In the reported study the hypothesis about beneficial properties of grasshopper abdominal secretion on hard to heal wounds was verified. The study was carried out with the use of a murine model (mice C57BL/6). In order to verify the beneficial properties of grasshopper abdominal secretion, the wounds of 8mm in diameter were formed on one side of each tested mouse. The influence of ethanolic extract of insects' secretion on healing process was evaluated in comparison to ethanolic solution of allantoin and 30% aqueous solution of ethanol (medium). The observation was carried out over a 14 day period. Finally the statistical analysis (ANOVA) was carried out to highlight the differences in wound healing rate between applied preparations. Moreover, qualitative composition of grasshoppers' secretion was studied with the use of GC/MS technique. During the first three days of observation, wounds treated with allantoin were healed with higher efficiency in comparison to ethanol and insect secretion preparations. The trend of healing changed from the 4th day of observation. Wounds treated with grasshoppers' abdominal secretion were closuring faster than wounds treated with allantoin or ethanol. In this part of observation, in the case of allantoin and ethanol application, the wound healing efficiency was similar. Since the 9th day of experiment the measurement of wounds size was problematic, due to crust formation. Finally at the 14th day of the study, wounds were totally healed. Morphological study enabled to observe all the phases of healing. In the 5th and 8th day, the infiltration of neutrophils and mononuclear cells in dermis was observed, which is characteristic for inflammatory phase
Park, Jun Hee; Kim, Hyeung Sun; Do, Nam Yong
Penetrating injuries to the upper cervical spine resulting from gunshots are rare in South Korea due to restrictions of gun use. Moreover, gunshot wounds to the upper cervical spine without neurological deficits occur infrequently because of the anatomic location and surrounding essential structures. We present an uncommon case involving the surgical removal of a bullet located in the anterior arch of first cervical vertebra (C1) via a transoral approach without neurological complications or subsequent mechanical instability. PMID:22639715
Sharma, Om P; Oswanski, Michael F; White, Patrick W
Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon.
Kelly, Paul; Drago, Carl J
Large defects of dentofacial structures may result from trauma, disease (including neoplasms), and congenital anomalies. The location and size of the defects are related to difficulties that patients report relative to speech, mastication, swallowing, facial esthetics, and self-image. This article reports on the evaluation and treatment of a patient who suffered significant trauma to the lower and mid-face secondary to a gunshot injury. It describes the initial presentation, life-saving procedures, and subsequent bone grafts, implant placement, and prosthetic treatments required to rehabilitate the patient to a condition that closely approximated his preoperative condition. This clinical report confirms that no matter the degree of complexity involved in treating the results of significant facial trauma, successful treatment is dependent on thorough physical and radiographic examinations, development of the appropriate diagnoses, and treatment based on sound prosthodontic and surgical principles.
Usui, Akihito; Kawasumi, Yusuke; Hosokai, Yoshiyuki; Kozakai, Masataka; Saito, Haruo; Funayama, Masato
Gunshot injury has always been an important field of investigation in postmortem forensic radiology. The localization and retrieval of the bullet and of potentially important fragments are vital to these cases. Using postmortem multidetector-row computed tomography (MDCT) prior to forensic autopsy, we sought to illustrate the importance of this modality in the noninvasive characterization of gunshot wounds. We obtained and analyzed MDCT images in three cases of gunshot wounds (accidental close-range shotgun shooting, suicidal contact gunshot to the head and accidental long-range buckshot shooting). We discuss the value of postmortem MDCT findings in gunshot wound cases by comparing with forensic autopsy findings in Japan, a developing country with miserably low autopsy rate. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Hur'iev, S O; Novykov, F M; Shuryhin, O Iu; Ivanov, V I
There were examined 131 injured persons, suffering penetrating abdominal wounding and hepatic injury. Correlation analysis was done, basing on studying of the results of the injured persons state estimation, using prognostic scales, aiming to prognosticate the traumatic process course.
Ricocheted bullets may still retain sufficient kinetic energy to cause gunshot injuries. Accordingly, this paper reviews the literature surrounding gunshot injuries caused by ricocheted bullets. In doing so, it discusses the characteristics of ricochet entrance wounds and wound tracks, noting several important considerations for assessment of a possible ricochet incident. The shapes of ricochet entrance wounds vary, ranging from round holes to elliptical, large and irregular shapes. Pseudo-stippling or pseudo-gunpowder tattooing, pseudo-soot blackening and tumbling abrasions seen on the skin surrounding the bullet hole are particularly associated with ricochet incidents. Ricocheted bullets have a reduced capability for tissue penetration. Most of the resulting wound tracks are short, of large diameter and irregular-all artefacts of the instability of a bullet that has ricocheted. A ricocheted hollow-point bullet, in particular, may overpenetrate the tissue when the bullet nose is deformed or fails to enter the body in a nose-forward orientation. Similarly, internal ricochet may occur when a bullet strikes hard tissue. Postmortem computed tomographic imaging is useful for localising a bullet and its fragments in the body and characterising the wound track. Ricochet cannot be ruled out in normal-appearing entrance wounds unless that finding is supported by other evidence, including the geometrical constraints of the shooting scene and the absence of ricochet marks and a ricocheted bullet. Copyright © 2017 Elsevier B.V. All rights reserved.
Singh, Swati; Prasad, Chandrakant
Background and Aims: Local infiltration of the surgical wound is one of the important components of multimodal analgesia for post-operative pain relief. This study determines the post-operative analgesic effect of addition of dexmedetomidine to bupivacaine for local infiltration of the surgical wound. Methods: Sixty women belonging to American Society of Anesthesiologists’ Grade 1 or 2 posted for abdominal hysterectomy were randomly allocated to Group I (control group) where patients received wound infiltration with 30 mL 0.25% bupivacaine at the end of surgery, or Group II, where patients received wound infiltration with 1.0 μg/kg dexmedetomidine diluted in 30 mL 0.25% bupivacaine. The primary objective of the study was to assess post-operative pain scores. Number of patients requiring rescue analgesia and total morphine consumption during 24 h after surgery were also recorded. Statistical significance for analgesic requirement was determined by one-way analysis of variance. Results: Pain scores were lower at rest for 12 h and on cough for 6 h in Group II (<0.01). All patients in Group I required supplemental morphine compared to only 3 patients in Group II (P < 0.003). Post-operative analgesia requirement was significantly less in patients receiving dexmedetomidine in wound infiltration compared to patients receiving bupivacaine alone (P < 0.001). Conclusions: Wound infiltration of dexmedetomidine with bupivacaine provides superior pain relief compared to bupivacaine alone. PMID:28655956
Škorpil, J; Vodička, J; Kohut, M; Žídková, A; Havelka, J
The authors present a case report of a 38-year-old man who suffered combined gunshot injuries of the heart and lungs from a small caliber gun. The gunshot resulted in combined injuries of a penetrating wound of the left lung, the right heart chambers and the right lung which were successfully managed despite a delay in surgery of several hours by pledget sutures of the heart wounds, wedge resection of the lingula and right lower lung lobectomy performed via a clamshell thoracotomy.
Bernini, C O; Junqueira, A R; Horita, L T; Birolini, D; Branco, P D; de Oliveira, M R
In patients having missile wounds, the most bizarre trajectories and lodgment sites have been reported. Entry of the missile into the blood stream and subsequent embolization is quite an uncommon event. Isolated reports published in the literature date back to the beginning of the century. This article was undertaken to present two instances of pulmonary embolism due to gunshot missiles. Most investigators agree that the missile should be removed when located in the pulmonary artery and its branches because of the high risk of severe complications, such as pulmonary infarction, secondary thrombosis, infection, erosion of the arterial wall and local hemorrhage. In such instances, a thoracotomy is recommended. The alternative treatment in the instances reported herein, conceived and successfully performed by us, was embolectomy through percutaneous cardiovascular catheterization. As a novel procedure, the method has proved effective and liable to minimal risk.
Henneman, P L
The management of patients with penetrating abdominal trauma is outlined in Figure 1. Patients with hemodynamic instability, evisceration, significant gastrointestinal bleeding, peritoneal signs, gunshot wounds with peritoneal violation, and type 2 and 3 shotgun wounds should undergo emergency laparotomy. The initial ED management of these patients includes airway management, monitoring of cardiac rhythm and vital signs, history, physical examination, and placement of intravenous lines. Blood should be obtained for initial hematocrit, type and cross-matching, electrolytes, and an alcohol level or drug screen as needed. Initial resuscitation should utilize crystalloid fluid replacement. If more than 2 liters of crystalloid are needed to stabilize an adult (less in a child), blood should be given. Group O Rh-negative packed red blood cells should be immediately available for a patient in impending arrest or massive hemorrhage. Type-specific blood should be available within 15 minutes. A patient with penetrating thoracic and high abdominal trauma should receive a portable chest x-ray, and a hemo- or pneumothorax should be treated with tube thoracostomy. An unstable patient with clinical signs consistent with a pneumothorax, however, should receive a tube thoracostomy prior to obtaining roentgenographic confirmation. If time permits, a nasogastric tube and Foley catheter should be placed, and the urine evaluated for blood (these procedures can be performed in the operating room). If kidney involvement is suspected because of hematuria or penetrating trauma in the area of a kidney or ureter in a patient requiring surgery, a single-shot IVP should be performed either in the ED or the operating room. An ECG is important in patients with possible cardiac involvement and in patients over the age of 40 going to the operating room. Tetanus status should be updated, and appropriate antibiotics covering bowel flora should be given. Operative management should rarely be delayed
Coban, Yusuf Kenan; Kalender, Ali Murat
Nonoperative therapy might be chosen for patients with small wounds or defects around the foot and ankle region. Lyophilized bovine collagen matrix is one of ideal biological dressings used in wound treatment. We present an example of type 1 bovine collagen (Gelfix, Euroresearch, Inc., Milano, Italy) usage in a complex gun-shot wound of the foot and relevant literature is discussed.
Shin, Jin Su; Choi, Hwan Jun
Necrotizing fasciitis (NF) is an aggressive soft-tissue infection involving the deep fascia and is characterized by extensive deterioration of the surrounding tissue. Immediate diagnosis and intensive treatment, including debridement and systemic antibiotics, represent the most important factors influencing the survival of NF patients. In this report, we present a case of NF in the abdomen due to an infection caused by a perforated small bowel after abdominal liposuction. It was successfully treated using negative-pressure wound therapy, in which a silicone sheet functioned as a barrier between the sponge and internal organs to protect the small bowel.
Landmann, Alessandra; Visoiu, Mihaela; Malek, Marcus M
Abdominal wall nerve blocks have been gaining popularity for the treatment of perioperative pain in children. Our aim was to compare a technique of surgeon-performed, laparoscopic abdominal wall nerve blocks to anesthesia-placed, ultrasound-guided abdominal wall nerve blocks and the current standard of local wound infiltration. After institutional review board approval was obtained, a retrospective chart review was performed of pediatric patients treated at a single institution during a 2-year period. Statistics were calculated using analysis of variance with post-hoc Bonferonni t tests for pair-wise comparisons. Included in this study were 380 patients who received ultrasound-guided abdominal wall nerve blocks (n = 125), laparoscopic-guided abdominal wall nerve blocks (n = 88), and local wound infiltration (n = 117). Groups were well matched for age, sex, and weight. There was no significant difference in pain scores within the first 8 hours or narcotic usage between groups. Local wound infiltration demonstrated the shortest overall time required to perform (P < .0001). Patients who received a surgeon-performed abdominal wall nerve block demonstrated a shorter duration of hospital stay when compared to the other groups (P = .02). Our study has demonstrated that laparoscopic-guided abdominal wall nerve blocks show similar efficacy to ultrasound-guided nerve blocks performed by pain management physicians without increasing time in the operating room. Copyright © 2017 Elsevier Inc. All rights reserved.
Bates, T.; Roberts, J. V.; Smith, K.; German, K. A.
In a randomized prospective trial of prophylactic antibiotics in at-risk abdominal surgery, one dose of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. Wound infection rates which included minor and delayed infections were very similar in those given one dose: 48/449 (10.7%) compared with those given three doses: 49/451 (10.9%) 95% confidence limits - 4.25% + 3.9%. There were more septic and sepsis-related deaths in those patients given one dose (14 deaths) than in those given three doses (7 deaths) P > 0.1 95% CL - 0.4% + 3.0%. However, there were more very elderly patients in the one dose group: 64% of the deaths were aged over 80 and all but one had an emergency operation. There was no difference in the other outcome measures studied which included non-fatal deep sepsis, length of postoperative hospital stay, duration of postoperative fever or the use of antibiotics for postoperative infection. One dose of a suitable intravenous antibiotic gives prophylaxis against wound infection in at-risk abdominal surgery which is at least as effective as multiple doses. However, there may be a risk of overwhelming systemic sepsis in very elderly patients having emergency surgery. PMID:1461853
Muhammad, Yar; Gondal, Khalid Masood; Khan, Umair Ahmed
To assess the efficacy of Bogota bag for closure of open abdominal wounds after laparotomy where the primary closure cannot be achieved and other closure techniques are not available. The descriptive study was conducted at Mayo Hospital, Lahore, Pakistan, from September 2011 to February2015, and comprised patients who underwent laparotomy and peritoneal cavities and who could not be closed primarily because of various reasons like traumatic loss and oedematous gut. They were managed with Bogota bag for abdominal closure. SPSS 18 was used for statistical analysis. Of the 55 patients, 37(67.27%) were male and 18(32.73%) were female. There was traumatic loss in 34(61.8%), oedematous gut and omentum in 15(27.27%) and gangrenous abdominal wall in 6(10.9%) patients. Bogota bag was applied in all (100%) of them. In 19(34.55%) patients, delayed primary closure was possible, so the Bogota was used temporarily. In 36(65.45%) cases managed with Bogota bag, healing occurred by granulation tissue or skin grafting/flaps were applied and these patients developed hernia. Five (9.09%) patients developed small bowel fistula which was managed conservatively. No patient developed complication due to exposure or abdominal compartment. There were 7(12.8%) postoperative deaths due to the disease process and were unrelated to the closure technique. Bogota bag was an effective means of closure of open abdominal wound and prevented the complications due to open abdominal wounds or closure under tension.
Dufresne, G W
In the United States the number of firearm-related deaths in 1989 was almost equal to the number of motor vehicle-related deaths. Trauma nurses could not imagine themselves caring for motor vehicle crash victims without any understanding of speed, vehicle damage, or collision angles. Gunshot wounds are becoming nearly as frequent as motor vehicle crashes, but the mechanism of injury for a gunshot wound is not as widely understood. This article explains the basics of wound ballistics, emergent care of the gunshot wound victim, and medicolegal concerns for the trauma nurse.
Zafar, S N; Nabeel Zafar, S; Rushing, A; Haut, E R; Kisat, M T; Villegas, C V; Chi, A; Stevens, K; Efron, D T; Zafar, H; Haider, A H
The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure. The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality. A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups. The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
Arunkumar, K V; Kumar, Sanjeev; Aggarwal, Rajat; Dubey, Prajesh
The use of firearms is becoming more prevalent in the society and hence the number of homicidal and suicidal cases. The severity of gunshot wounds varies depending on the weapons caliber and the distance of firing. Close-range, high-velocity gunshot wounds in the head and neck region can result in devastating esthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstructions. Here we present the successful management of a patient shot by a low-velocity short-range pistol with basic life support measures, wound management, reconstruction, and rehabilitation.
Pinto, Antonio; Brunese, Luca; Scaglione, Mariano; Scuderi, Maria Giuseppina; Romano, Luigia
The neck is an interesting structure as far as penetrating trauma is concerned because of the multiple vital structures that are concentrated in a small anatomic area. Gunshot wounding is an interaction between the penetrating projectile, the anatomy of the wounded subject, and the chance occurrences that determine the exact missile path. The mass and velocity of the projectile establish the upper limit of possible tissue damage. Management of gunshot neck injuries depends on a clear understanding of the anatomy of the neck. The radiologist can contribute substantially to the successful treatment of the patient with a gunshot wound. Important analysis includes the assessment of the missile path in emergency conditions by using plain film and multidetector row computed tomography. The radiologist further evaluates the extent of wounding by determining missile fragmentation and secondary missile paths.
Kunz, Sebastian Niko; Meyer, Harald J; Kraus, Sybille
Suicidal gunshot wounds are a common appearance in forensic casework. The main task of the coroner lies in the detection of typical pathomorphological correlates, thus differentiating between homicide, suicide and accident. Apart from characteristic bloodstain patterns on the gun and shooting hand, the localisation of the entrance wound and the position of the weapon, additional details such as family background or medical history are important aspects of forensic investigation. An uncommon choice of weaponry and its unusual morphological manifestation often complicate the examination and reconstruction of such cases. Furthermore, due to social stigmatisation, the possibility of secondary changes by relatives at the crime scene should be considered. In addition to autopsy findings, a careful crime scene investigation and bloodstain pattern analysis, a ballistic reconstruction can be an essential tool to gain knowledge of the shooting distance and position of the gun.
Mohamed, S A; Sayed, D M; El Sherif, F A; Abd El-Rahman, A M
Postoperative pain and stress elicit hormonal changes. We aimed at comparing the effects of wound infiltration with ketamine versus dexmedetomidine on postoperative pain and stress response. This double-blinded study included ninety patients scheduled for total abdominal hysterectomy and were randomly assigned into three groups to receive local wound infiltration with 40 mL of 0.25% bupivacaine (group C), plus 2 mg/kg ketamine (group K) or 2 μg/kg dexmedetomidine (group D). Primary outcome was postoperative morphine consumption; secondary outcomes included first request of analgesia, VAS scores at rest and movement (VAS-R/M) and side effects. Serum cortisol, prolactin and glucose levels at baseline, pre-infiltration, 6 and 24 h postoperatively were measured. Rescue analgesia was less in K (6.80 ± 3.19 mg) and D (8.39 ± 3.86 mg) compared to C (13.33 ± 4.01 mg) (p < 0.05). First request of analgesia was delayed in K (7.60 ± 4.16 h) and D (6.00 ± 3.73 h) compared to C (4.20 ± 1.13 h) (p < 0.05). Both VAS and R/M were significantly lower in K (all over 24 h) and D (for 8 and 4 h, respectively) compared to C. Stress markers were significantly lower in K and D compared to C at 6 and 24 h, and in K compared to D at 24 h (p < 0.05). Local wound infiltration with ketamine or dexmedetomidine added to bupivacaine had an opioid-sparing effect, delayed first request of rescue analgesia, and attenuated postoperative stress response, especially with ketamine in patients underwent total abdominal hysterectomy. © 2018 European Pain Federation - EFIC®.
Ventham, N T; Hughes, M; O'Neill, S; Johns, N; Brady, R R; Wigmore, S J
Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia. A meta-analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen(continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter-related complications and treatment failure. Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non-significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group. Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure-specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.
Scialpi, M; Magli, T; Boccuzzi, F; Scapati, C
The knowledge of wound ballistics and of wounding mechanisms is mandatory for the radiologist to interpret the CT findings of gunshot wounds. The severity of a bullet wound depends on the characteristics of the tissue it goes through, i.e., tissue elasticity, density, thickness of the wounded body part, the type of tissue, its specific gravity, internal cohesiveness and anatomical relationships, as well as on missile characteristics, i.e., mass, shape, fragmentation and deformation. Bullet velocity is certainly a major factor in wounding, but it is only one factor. Two major wounding mechanisms exist the crushing of the bullet-struck tissue (forming the permanent cavity) and radial stretching (forming a temporary cavity). Bullet "yaw" is defined as the angle between the long axis of the bullet and its flight path. The yaw is directly proportional to tissue crushing and stretching: the wider the yaw, the most severe tissue crushing and stretching and, therefore, the more severe tissue damage. The basic knowledge of these concepts is of the utmost importance to understand the CT findings of gunshot wounds and can help physicians study and treat gunshot wounds.
Kumar, Senthil; Rao, Murali G
Assault on pregnant women is not a rare event; however forensic analysis of gunshot injuries among the same group requires a greater deliberation. This is the report of a 38-week-old fetus which succumbed following gunshot injuries to the mother while the latter survived. The uniqueness of fetal injuries in the form of avulsed wound with complete detachment of anus is of great forensic interest. Such unusual wound pattern could have been the result of a blast wave effect created due to the high velocity projectile affecting the fluid filled uterine cavity. PMID:26435965
Rana, Majeed; Warraich, Riaz; Rashad, Ashkan; von See, Constantin; Channar, Kashif A; Rana, Madiha; Stoetzer, Marcus; Gellrich, Nils-Claudius
Firearm injuries continue as a major public health problem, contributing significant morbidity, mortality, and expense to our society. There are four main steps in the management of patients with gunshot wounds to the face: securing an airway, controlling haemorrhage, identifying other injuries and definitive repair of the traumatic facial deformities. The objective of this study was to determine late outcome of two treatment options by open reduction and internal fixation versus closed reduction and maxillomandibular fixation (MMF) in the treatment of gunshot injuries of the mandible. Sixty patients of gunshot injury were randomly allocated in two groups. In group A, 30 patients were treated by open reduction and internal fixation and in group B, 30 patients were treated by closed reduction and maxillomandibular fixation. Patients were discharged as the treatment completed and recalled for follow up. Up to 3 months after injury, fortnightly complications like infection, malocclusion, malunion of fractured fragments, facial asymmetry, sequestration of bone and exposed plates were evaluated and the differences between two groups were assessed. The follow-up period ranged from 3 months to 10 months. Patients treated by open reduction tended to have less complications as compared to closed reduction. Based on this study open reduction and internal fixation is the best available method for the treatment of gunshot mandible fractures without continuity defect. Copyright © 2012 Elsevier Ltd. All rights reserved.
Onyia, Ephraim Eziechina; Chikani, Mark C; Mezue, Wilfred C; Uche, Enoch O; Iloabachie, Izuchukwu; Mesi, Matthew; Ejembi, Sunday; Agunwa, Chuka
Introduction: Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. Materials and Methods: Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004–2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. Results: Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. Conclusions: Admitting GCS and bullet trajectory were predictive of outcome. PMID:28584512
Onyia, Ephraim Eziechina; Chikani, Mark C; Mezue, Wilfred C; Uche, Enoch O; Iloabachie, Izuchukwu; Mesi, Matthew; Ejembi, Sunday; Agunwa, Chuka
Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded. Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004-2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed. Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality. Admitting GCS and bullet trajectory were predictive of outcome.
Güsgen, Christoph; Willms, Arnulf; Richardsen, Ines; Bieler, Dan; Kollig, Erwin; Schwab, Robert
Much like other countries, Germany has recently seen terrorist attacks being planned, executed or prevented at the last minute. This highlights the need for expertise in the treatment of penetrating torso traumas by bullets or explosions. Data on the treatment of firearm injuries and, even more so, blast injuries often stems from crises or war regions. However, it is difficult to compare injuries from such regions with injuries from civilian terrorist attacks due to the ballistic body protection (protective vests, body armour) worn by soldiers. Methods An analysis was performed based on data from patients who were treated in the German Military Hospital Mazar-e Sharif for gunshots or injuries from explosions in the years 2009 to 2013. The data selection was based on patients with penetrating injuries to the thorax and/or abdomen. For better comparability with civilian attack scenarios, this study only included civilian patients without ballistic body protection (body armour, protective vests). Results Out of 117 analysed patients, 58 were affected by firearms and 59 by explosive injuries of the thorax or abdomen. 60% of patients had a thoracic injury, 69% had an abdominal injury, and 25.6% had combined thoracic-abdominal injuries. Blast injury patients were significantly more affected by thoracic trauma. As regards abdominal injuries, liver, intestinal, and colonic lesions were leading in number. Patients with blast injuries had significantly more injured organs and a significantly higher ISS averaging 29. 26% of the shot patients and 41% of the blast wounded patients received Damage Control Surgery (DCS). Despite a lower ISS, gunshot victims did not have a lower total number of operations per patient. Overall mortality was 13.7% (10.3% gunshot wounds, 16.7% blast injury). The highest mortality rate (25.7%) was recorded for patients with combined thoracoabdominal injuries (vs. 8.3% for thoracic and 8.7% for abdominal injuries). The ISS of deceased patients was
Biffl, Walter L; Kaups, Krista L; Pham, Tam N; Rowell, Susan E; Jurkovich, Gregory J; Burlew, Clay Cothren; Elterman, J; Moore, Ernest E
The optimal management of stable patients with anterior abdominal stab wounds (AASWs) remains a matter of debate. A recent Western Trauma Association (WTA) multicenter trial found that exclusion of peritoneal penetration by local wound exploration (LWE) allowed immediate discharge (D/C) of 41% of patients with AASWs. Performance of computed tomography (CT) scanning or diagnostic peritoneal lavage (DPL) did not improve the D/C rate; however, these tests led to nontherapeutic (NONTHER) laparotomy (LAP) in 24% and 31% of cases, respectively. An algorithm was proposed that included LWE, followed by either D/C or admission for serial clinical assessments, without further imaging or invasive testing. The purpose of this study was to evaluate the safety and efficacy of the algorithm in providing timely interventions for significant injuries. A multicenter, institutional review board-approved study enrolled patients with AASWs. Management was guided by the WTA AASW algorithm. Data on the presentation, evaluation, and clinical course were recorded prospectively. Two hundred twenty-two patients (94% men, age, 34.7 years ± 0.3 years) were enrolled. Sixty-two (28%) had immediate LAP, of which 87% were therapeutic (THER). Three (1%) died and the mean length of stay (LOS) was 6.9 days. One hundred sixty patients were stable and asymptomatic, and 81 of them (51%) were managed entirely per protocol. Twenty (25%) were D/C'ed from the emergency department after (-) LWE, and 11 (14%) were taken to the operating room (OR) for LAP when their clinical condition changed. Two (2%) of the protocol group underwent NONTHER LAP, and no patient experienced morbidity or mortality related to delay in treatment. Seventy-nine (49%) patients had deviations from protocol. There were 47 CT scans, 11 DPLs, and 9 laparoscopic explorations performed. In addition to the laparoscopic procedures, 38 (48%) patients were taken to the OR based on test results rather than a change in the patient's clinical
Puskas, Cathy M
Approximately half of the skeleton of an adult male (minus the cranium) was found in a forested part of Greater Vancouver, Canada, in August 2000 by the Royal Canadian Mounted Police (RCMP). Authorities ruled the death as suicide. The only compelling signs of perimortem trauma were symmetrically fractured coronoid processes of the mandible, which can be attributed to a gunshot in the mouth. However, the remains had also been scavenged by canids, raising a problem in differential diagnosis. Could canid scavenging produce bilateral fracturing of the mandible indistinguishable from gunshot wounds to the mouth? We found that canid scavengers could not mimic the type of damage to the mandible caused by intra-oral gunshot wounding using a sheep model (n = 20). Bilateral fracturing of the coronoid processes was found to be characteristic of intra-oral gunshot wounding, while canid scavengers typically ignore this region of the mandible.
Ojo, Emmanuel Olorundare; Ozoilo, Kenneth N.; Sule, Augustine Z.; Ugwu, Benjamin T.; Misauno, Michael A.; Ismaila, Bashiru O.; Peter, Solomon D.; Adejumo, Adeyinka A.
Background: Abdominal injuries contribute significantly to battlefield trauma morbidity and mortality. This study sought to determine the incidence, demographics, clinical features, spectrum, severity, management, and outcome of abdominal trauma during a civilian conflict. Materials and Methods: A prospective analysis of patients treated for abdominal trauma during the Jos civil crises between December 2010 and May 2012 at the Jos University Teaching Hospital. Results: A total of 109 victims of communal conflicts with abdominal injuries were managed during the study period with 89 (81.7%) males and 20 (18.3%) females representing about 12.2% of the total 897 combat related injuries. The peak age incidence was between 21 and 40 years (range: 3–71 years). The most frequently injured intra-abdominal organs were the small intestine 69 (63.3%), colon 48 (44%), and liver 41 (37.6%). Forty-four (40.4%) patients had extra-abdominal injuries involving the chest in 17 (15.6%), musculoskeletal 12 (11%), and the head in 9 (8.3%). The most prevalent weapon injuries were gunshot 76 (69.7%), explosives 12 (11%), stab injuries 11 (10.1%), and blunt abdominal trauma 10 (9.2%). The injury severity score varied from 8 to 52 (mean: 20.8) with a fatality rate of 11 (10.1%) and morbidity rate of 29 (26.6%). Presence of irreversible shock, 3 or more injured intra-abdominal organs, severe head injuries, and delayed presentation were the main factors associated with mortality. Conclusion: Abdominal trauma is major life-threatening injuries during conflicts. Substantial mortality occurred with loss of nearly one in every 10 hospitalized victims despite aggressive emergency room resuscitation. The resources expenditure, propensity for death and expediency of timing reinforce the need for early access to the wounded in a concerted trauma care systems. PMID:26957819
A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions.
Timmermans, Floyd W; Westland, Pèdrou B; Hummelink, Stefan; Schreurs, Joep; Hameeteman, Marijn; Ulrich, Dietmar J O; Slater, Nicholas J
The deep inferior epigastric artery perforator (DIEP) flap is one of the most common techniques for breast reconstruction. Body mass index (BMI) is considered as an important predictor of donor site healing complications such as wound dehiscence. The use of computed tomography (CT) proved to be a precise and objective method to assess visceral adipose tissue. It remains unclear whether quantification of visceral fat provides more accurate predictions of abdominal wound healing complications than BMI. A total of 97 patients with DIEP flap were retrospectively evaluated. Patients' abdominal visceral fat (AVF) was quantified on CT angiography (CTA). The patients were postoperatively assessed for abdominal wound healing complications. We analyzed for the correlations between AVF, BMI, and dehiscence and established a logistic regression model to assess the potential high-profile predictors in anatomic and patient characteristics such as weight, smoking, and diabetes. We included 97 patients, and of them, 24 patients (24.7%) had some degree of abdominal dehiscence. No significant differences were observed between the dehiscence group and the non-dehiscence group, except for smoking (p = 0.002). We found a significant correlation between AVF and BMI (R = 0.282, p = 0.005), but neither was significant in predicting donor site dehiscence. Smoking greatly increased the likelihood of developing wound dehiscence (OR = 11.4, p = < 0.001). AVF and BMI were not significant predictors of abdominal wound healing complications after DIEP flap reconstruction. This study established active smoking (OR = 11.4, p = < 0.001) as the significant risk factor that contributed to the development of abdominal wound dehiscence in patients with DIEP. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Willms, A; Schaaf, S; Schwab, R; Richardsen, I; Bieler, D; Wagner, B; Güsgen, C
The open abdomen has become a standard technique in the management of critically ill patients undergoing surgery for severe intra-abdominal conditions. Negative pressure and mesh-mediated fascial traction are commonly used and achieve low fistula rates and high fascial closure rates. In this study, long-term results of a standardised treatment approach are presented. Fifty-five patients who underwent OA management for different indications at our institution from 2006 to 2013 were enrolled. All patients were treated under a standardised algorithm that uses a combination of vacuum-assisted wound closure and mesh-mediated fascial traction. Structured follow-up assessments were offered to patients and included a medical history, a clinical examination and abdominal ultrasonography. The data obtained were statistically analysed. The fascial closure rate was 74 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. The fistula rate was 1.8 %. Thirty-four patients attended follow-up. The median follow-up was 46 months (range 12-88 months). Incisional hernias developed in 35 %. Patients with hernias needed more operative procedures (10.3 vs 3.4, p = 0.03) than patients without hernia formation. A Patient Observer Scar Assessment Scale (POSAS) of 31.1 was calculated. Patients with symptomatic hernias (NAS of 2-10) had a significantly lower mean POSAS score (p = 0.04). Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) seem to result in low complication rates and high fascial closure rates. Abdominal wall reconstruction, which is a challenging and complex procedure and causes considerable patient discomfort, can thus be avoided in the majority of cases. Available results are based on studies involving only a small number of cases. Multi-centre studies and registry-based data are therefore needed to validate these findings.
Yinusa, W; Ogirima, M O
A combined retrospective and prospective study of Gunshot Injuries (GSI) that presented to the National Orthopaedic Hospital, Igbobi (NOHL) between 1991 and 1995 was undertaken with the aim of determining the characteristics of these injuries in Lagos, Nigeria. 232 patients with 281 gunshot wounds and 212 gunshot fractures were seen during this period. 68.9% of patients in the study were in the age group 21-40 years with a mean age at presentation of 32.46 +/- 11.21 years. The male to female ratio was 9:1. 87 (37.5%) presented within 6 hours of injury. Armed robbery dominated the events surrounding the shootings with high velocity weapon (HVW) accounting for 47% of the cases. While the femur was the commonest single bone to be fractured the treatment of fractures generally was largely conservative as only 5 fractures were eventually treated by open reduction and internal fixation. Wound infection was the commonest complication (25%) with amputation being performed in 5.6% of cases. This study does not confirm the belief that high velocity weapon causes greater morbidity than low velocity weapon. Even though the average duration of hospitalisation was 33.5 +/- 23.4 days, we advise that for our present state of development gunshot fractures should not be primarily treated with internal fixation.
Ptaszyńska-Sarosiek, Iwona; Filimoniuk, Karolina; Cwalina, Urszula; Niemcunowicz-Janica, Anna
Aim of the study was to assess gunshot fatalities on the basis of post-mortem examination reports collected at the Department of Forensic Medicine in the Medical University of Białystok. Material and methods: The research covered 87 gunshot fatalities occurring in the Podlasie district (north-eastern Poland) over the period from 1964 to 2015. The analysis included demographic data such as the victims' gender, age, place of residence and such data as time of year, circumstances of the event and causes of death. The study also investigated blood alcohol level in the victims. The results were analysed statistically using the Mann-Whitney and Kruskal-Wallis tests. Results: The majority of victims were young males, most of whom committed suicide. The most common cause of death among the suspected suicides was gunshot wounds in the skull area. The second most frequent gunshot wound location among non-suicides was the chest. The majority of male victims were intoxicated at the time of death. Conclusions: In the area of the city of Bialystok and its surroundings, there are approximately two gunshot fatalities per year. In most cases, the victims were urban-dwelling young males (aged 21-30) committing suicide. The most common cause of death among the suspected suicides was gunshot wounds in the skull area and the chest. The majority of male victims were intoxicated at the time of death.
Tilleul, P; Aissou, M; Bocquet, F; Thiriat, N; le Grelle, O; Burke, M J; Hutton, J; Beaussier, M
Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques. A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed. When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA. Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.
Clarke, Damian L; Gall, Tamara M H; Thomson, Sandie R
In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy. All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death. Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group. Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an
Fischer, Tatjana V; Folio, Les R; Backus, Christopher E; Bunger, Rolf
Penetrating trauma is frequently encountered in forward deployed military combat hospitals. Abdominal blast injuries represent nearly 11% of combat injuries, and multiplanar computed tomography imaging is optimal for injury assessment and surgical planning. We describe a multiplanar approach to assessment of blast and ballistic injuries, which allows for more expeditious detection of missile tracts and damage caused along the path. Precise delineation of the trajectory path and localization of retained fragments enables time-saving and detailed evaluation of associated tissue and vascular injury. For consistent and reproducible documentation of fragment locations in the body, we propose a localization scheme based on Cartesian coordinates to report 3-dimensional locations of fragments and demonstrating the application in three cases of abdominal blast injury.
Sathiyakumar, Vasanth; Thakore, Rachel V; Stinner, Daniel J; Obremskey, William T; Ficke, James R; Sethi, Manish K
The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and
Schoenfeld, Andrew J; Dunn, John C; Bader, Julia O; Belmont, Philip J
Previous studies regarding combat wounding have a limited translational capacity due to inclusion of soldiers from all military branches and occupational specialties as well as a lack of information regarding soldiers who died in theater. A search was performed of the Department of Defense Trauma Registry and Armed Forces Medical Examiner data set for the years 2003 to 2011 to identify all injured personnel with the military specialty 19D (cavalry scout). A manual search was conducted for each record identified, and age, rank, location and manner of injury, mechanism of injury, Injury Severity Score (ISS), and extent of wounding were abstracted. The incidence of injuries by body region and rates for specific types of wounds were determined. Statistically significant associations between rank, location of injury, manner of injury, body region involved, and injury mechanism were assessed using χ2 analysis. Associations between ISS, rank, manner of injury, and survival were evaluated by t test with Satterthwaite correction. A total of 701 casualties were identified with 3,189 distinct injuries. Mean (SD) age of injured personnel was 25.9 (6.0) years. Thirty-five percent of the cohort was composed of soldiers who died in theater. Explosions were the most common mechanism of injury (70%), while 18% of wounds occurred owing to gunshot. Extremity wounds and injuries to the head and neck represented 34% of casualty burden. Thoracic trauma occurred in 16%, and abdominal injuries occurred in 17%. Wounds with a frequency exceeding 5% included skin, extremity, facial, brain, and gastrointestinal injuries. Vascular injury occurred in 4%. Gunshot wounds were a greater cause of injury in Afghanistan (p = 0.001) and resulted in a higher percentage of thoracic injuries (p < 0.001). The nature and extent of trauma sustained by combat-specific personnel seems to be different from that experienced by all soldiers deployed to a war zone.
Khrupkin, V I; Nemchenko, N S
Results of clinico-physiological, pathobiochemical, immunological and hemocoagulative studies performed at the postshock period in 186 patients with battle wounds have shown their coincidence with data obtained in critical mechanical trauma of peace-time. A conclusion is made that critical gunshot wounds are followed by trauma disease having main regularities similar to those in a critical mechanical trauma of peace-time. One can speak only about specific features of battle injuries, but to distinguish "wound disease" as an independent clinical form is thought to be illegal.
Saedi, B; Ghasemi, M; Motiee, M; Mojtahed, M; Safavi, A
Many people, such as soldiers, are routinely exposed to gunshot noise during target practice. It is suspected that this high-intensity noise may affect audition through repeated Transient Threshold Shifts (TTS); it can also mechanically alter auditory components such as waves. This study investigates the scope of gunshot noise from the AK-47 rifle (Kalashnikov) and the impact on the shooters' audition. Forty soldiers (80 ears) were recruited in this study. They were all young and being exposed to gunshot noise for the first time. Gunshot characteristics were measured before exposure. The soldiers underwent auditory evaluation with Pure Tone Audiometry (PTA) and Oto-Acoustic Emission (OAE) once before exposure and immediately (less than one hour) after exposure. The AK-47 gunshot noise pressure level varied between L(AIm) = 73.7 dBA to L(AIm) = 111.4 dBA. Fourteen participants had subclinical hearing impairment in their pre-exposure evaluation; this number increased to 16 after the exposure. Six months post-exposure and later, the number of cases with impairment had fallen to eight (improvement in 50%). Both pre- and post-exposure OAE results were within normal values, while PTA results indicated a significant threshold alteration only at 6 kHz. The results of this study confirm that exposure to gunshot noise with no ear protection can represent a significant hazard for auditory function, especially at higher frequencies.
Vatsyayan, Ashutosh; Adhyapok, Apurba-Kumar; Debnath, Subhas-Chandra; Malik, Kapil
Gunshot injuries are always known to cause severe morbidity and mortality when head and neck are involved. They vary in morbidity, which can occur in civilian surroundings. The wound largely depends on the type of weapon, mass and velocity of the bullet, and the distance from where it has been shot. Close-range gunshot wounds in the head and neck region can result in devastating aesthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstruction. Here we presented the successful management of three patients shot by short-range pistol with basic life support measures, wound management, reconstruction and rehabilitation.
Capak, Hrvoje; Brkljaca Bottegaro, Nika; Manojlovic, Ana; Smolec, Ozren; Vnuk, Drazen
The study is aimed to establish predilection signalment and history data, and to investigate clinical findings and risk factors associated with a poor outcome in dogs with projectile injuries. A retrospective study was undertaken of 166 canine cases in which a projectile was found on radiograph in a university׳s diagnostic imaging center more than a 4-year period. The study included dogs with both apparent (obvious recent traumatic event) and incidental (traumatic event unknown to the owner) projectile injury. Radiographs were reviewed and data regarding projectile position according to body region, number and type of projectile(s), bone fracture(s), and wound(s) related to projectile were recorded. The dogs were divided into groups according to owner address, hunting accident vs. shooting unrelated to hunting, and projectile type found on radiographs. Overall, 160 dogs met the inclusion criteria, making 0.76% the incidence of gunshot injuries. Further, 91 dogs were received with incidental projectile injury, and 75 dogs had apparent projectile injury. Male dogs were overrepresented (74.1%). Hunting accidents were the cause of projectile injury in 12.7% of cases. Fractures were observed in 20.5% of dogs. Most of the dogs (62%) were from an urban area, and the most common projectile type was airgun projectile (62%). The risk of fatal outcome was 14.4 times higher in dogs with thoracic injuries. Projectile injuries are still a real cause of trauma, especially in urban areas and in male dogs. Most gunshot injuries do not cause fatalities, although the thoracic projectile injury was associated with a greater fatality risk. Copyright © 2016 Elsevier Inc. All rights reserved.
Udosen, A M; Etiuma, A U; Ugare, G A; Bassey, O O
Gunshot injuries were rare in Calabar before the Nigerian civil war. This has changed in subsequent years and has reached a near epidemic proportion in the last three years. These are caused by civil violence, police brutality and armed robberies. To evaluate the incidence, pattern and causes of gunshot injuries in this region and draw the attention of Nigerians and the Government to the above problems for a possible solution. Records of patients admitted into the University of Calabar Teaching Hospital (UCTH) with gunshot wounds between April 2002 and May 2004 were extracted. Parameters analyzed included patients' biodata, sources of injury, anatomical site (s) of injury, modalities of treatment and the outcome There were 51 injuries in 49 patients as follows: The lower limbs 25 (51'), upper limbs 6 (12.4'), upper limbs/ chest 2 (4.1'), chest 4 (8.2'), abdomen 7(14.1') and head/neck 5(10.2'). Male/female ratio was 48:1. Twenty-four (49') sustained their injuries from either accidental discharge or deliberate shooting by the police while armed robbers wounded 10 (20.4') and cultists, 2 (4.1'). Two patients had amputations and mortality was 8.2'. The police should be cautious with guns;they and the Government should be alert to the menace of robbery, political violence, cultism and communal clashes. Good Governance, creation of employment, eradication of corruption and political violence may help.
Toutouzas, Konstantinos G; Larentzakis, Andreas; Drimousis, Panagiotis; Riga, Maria; Theodorou, Dimitrios; Katsaragakis, Stylianos
Introduction One of the most lethal mechanisms of injury is shotgun wound and particularly the abdominal one. Case presentation We report a case of a 45 years old male suffering abdominal shotgun trauma, who survived his injuries. Conclusion The management of the abdominal shotgun wounds is mainly dependent on clinical examination and clinical judgment, while requires advanced surgical skills. PMID:18625076
Loeffler, Charles E
Gun violence continues to be a staggering and seemingly intractable issue in many communities. The prevalence of gun violence among the sub-population of individuals under court-ordered community supervision provides an opportunity for intervention using remote monitoring technology. Existing monitoring systems rely heavily on location-based monitoring methods, which have incomplete geographic coverage and do not provide information on illegal firearm use. This paper presents the first results demonstrating the feasibility of using wearable inertial sensors to recognize wrist movements and other signals corresponding to firearm usage. Data were collected from accelerometers worn on the wrists of subjects shooting a number of different firearms, conducting routine daily activities, and participating in activities and tasks that could be potentially confused with firearm discharges. A training sample was used to construct a combined detector and classifier for individual gunshots, which achieved a classification accuracy of 99.4 percent when tested against a hold-out sample of observations. These results suggest the feasibility of using inexpensive wearable sensors to detect firearm discharges.
Loeffler, Charles E.
Gun violence continues to be a staggering and seemingly intractable issue in many communities. The prevalence of gun violence among the sub-population of individuals under court-ordered community supervision provides an opportunity for intervention using remote monitoring technology. Existing monitoring systems rely heavily on location-based monitoring methods, which have incomplete geographic coverage and do not provide information on illegal firearm use. This paper presents the first results demonstrating the feasibility of using wearable inertial sensors to recognize wrist movements and other signals corresponding to firearm usage. Data were collected from accelerometers worn on the wrists of subjects shooting a number of different firearms, conducting routine daily activities, and participating in activities and tasks that could be potentially confused with firearm discharges. A training sample was used to construct a combined detector and classifier for individual gunshots, which achieved a classification accuracy of 99.4 percent when tested against a hold-out sample of observations. These results suggest the feasibility of using inexpensive wearable sensors to detect firearm discharges. PMID:25184416
Poppa, Pasquale; Porta, Davide; Gibelli, Daniele; Mazzucchi, Alessandra; Brandone, Alberto; Grandi, Marco; Cattaneo, Cristina
The study of skin and bone lesions may give information concerning type and manner of production, but in burnt material modification of tissues by the high temperatures may considerably change the morphological characteristics of the lesions. This study aims at pointing out the effects of burning head of pigs with several types of lesions (blunt trauma, sharp force, and gunshot lesions) on soft tissues and bones, both from a morphological and chemical point of view. Results show that the charring process does not completely destroy signs of lesions on bones, which can often be recovered by cleaning bone surface from charred soft-tissue residues. Furthermore, neutron activation analysis test proved that antimony may be detectable also on gunshot entry wounds at the final stages of charring process.
Macedo, F I B; Sciarretta, J D; Otero, C A; Ruiz, G; Ebler, D J; Pizano, L R; Namias, N
Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.
Demetriades, Demetrios; Hadjizacharia, Pantelis; Constantinou, Costas; Brown, Carlos; Inaba, Kenji; Rhee, Peter; Salim, Ali
Objective: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries. Background: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs. Patients and Methods: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay. Results: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a “blush” on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27
Oztürk, Serdar; Bozkurt, Ali; Durmus, Muzaffer; Deveci, Mustafa; Sengezer, Mustafa
The studies of maxillofacial gunshot injuries mainly focused on evaluating the surgical interventions and physical outcomes of the procedures. In this study we aimed to analyze the pre- and post-injury psychiatric status of the patients with self-inflicted gunshot wounds to the face. This study is based on 12 subjects who attempted suicide resulting in extensive maxillofacial injuries using guns placed beneath their chins. The psychiatric evaluation was conducted by interview and using SCID-I, SCID-II, MMPI, Rosenberg Self-Esteem Scale and Suicide Probability Scale. Two subjects were healthy, 1 had bereavement, 6 had current and 5 had previous MDD (major depressive disorder), 2 had dysthymic disorder, 3 had alcohol abuse, 2 had drug abuse and 4 had antisocial personality disorder. The suicidal group was more socially introverted according to MMPI. According to Rosenberg self-esteem subscale, self esteem, the constancy of self respect and depressive mood subtests were statistically significant in the suicide group compared to the healthy controls (P < 0.01). Depressive spectrum disorders are the most common causes. It is obvious that untreated or undiagnosed depression may increase risk of committing suicide. The changes in the physical facial appearance after the suicide attempt caused impairment of self-esteem and the constancy of self-respect. Similar to other studies, none of our patients reattempted suicide and all tried to return to their pre-injury lifestyle and appeared to accommodate to the stigma of their physical deformities. Early diagnosis and treatment should be considered as a factor to reduce the risk for suicide attempt.
Berens, Sandra; Ketterer, Thomas; Kneubuehl, Beat P; Thali, Michael J; Ross, Steffen; Bolliger, Stephan A
Determination of the manner of death in case of intraoral firearm wounds can be a challenge, especially if the circumstances of the incident are unclear and crime scene investigation is inadequate. It is a well-known fact that the mouth is one of the selected sites for suicide with firearms. Homicidal shooting through the mouth is said to be rare, but does occur, and can be mistaken for a suicide. For discrimination between suicide and homicide in cases of intraoral firearm wounds, some useful points are the site of entry wound, the direction of the internal bullet path, the range of fire and the circumstances of death. We demonstrate these points in a case of a homicidal gunshot to the mouth assessed by both classical autopsy and post-mortem CT (PMCT).
Carey, M E; Sarna, G S; Farrell, J B; Happel, L T
Among civilians in the United States, 33,000 gunshot wound deaths occur each year; probably half of these involve the head. In combat, head wounds account for approximately half of the immediate mortality when death can be attributed to a single wound. No significant reduction in the neurosurgical mortality associated with these wounds has occurred between World War II and the Vietnam conflict, and very little research into missile wounds of the brain has been undertaken. An experimental model has been developed in the anesthetized cat whereby a ballistic injury to the brain may be painlessly reproduced in order that the pathophysiological effects of brain wounding may be studied and better treatments may be designed to lower the mortality and morbidity rates associated with gunshot wounds. Prominent among physiological effects observed in this model was respiratory arrest even though the missile did not injure the brain stem directly. The incidence of prolonged respiratory arrest increased with increasing missile energy, but arrest was often reversible provided respiratory support was given. It is possible that humans who receive a brain wound die from missile-induced apnea instead of brain damage per se. The mortality rate in humans with brain wounding might be reduced by prompt respiratory support. Brain wounding was associated with persistently increased intracranial pressure and reduced cerebral perfusion pressure not entirely attributable to intracranial bleeding. The magnitude of these derangements appeared to be missile energy-dependent and approached dangerous levels in higher-energy wounds. All wounded cats exhibited postwounding increases in blood glucose concentrations consistent with a generalized stress reaction. A transient rise in hematocrit also occurred immediately after wounding. Both of these phenomena could prove deleterious to optimal brain function after injury.
Thali, Michael J; Schweitzer, Wolf; Yen, Kathrin; Vock, Peter; Ozdoba, Christoph; Spielvogel, Elke; Dirnhofer, Richard
The goal of this study was the full-body documentation of a gunshot wound victim with multislice helical computed tomography for subsequent comparison with the findings of the standard forensic autopsy. Complete volume data of the head, neck, and trunk were acquired by use of two acquisitions of less than 1 minute of total scanning time. Subsequent two-dimensional multiplanar reformations and three-dimensional shaded surface display reconstructions helped document the gunshot-created skull fractures and brain injuries, including the wound track, and the intracerebral bone fragments. Computed tomography also demonstrated intracardiac air embolism and pulmonary aspiration of blood resulting from bullet wound-related trauma. The "digital autopsy," even when postprocessing time was added, was more rapid than the classic forensic autopsy and, based on the nondestructive approach, offered certain advantages in comparison with the forensic autopsy.
Martin, Case; Thiart, Gerhard; McCollum, Graham; Roche, Stephen; Maqungo, Sithombo
Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient
... Clearinghouse What are abdominal adhesions? Abdominal adhesions are bands of fibrous tissue that can form between abdominal ... Esophagus Stomach Large intestine Adhesion Abdominal adhesions are bands of fibrous tissue that can form between abdominal ...
... and Recurrent or Functional Abdominal Pain (RAP or FAP) What is abdominal pain? Abdominal pain , or stomachache, ... recurrent abdominal pain (RAP) or functional abdominal pain (FAP)? If your health care provider has ruled out ...
Boracchi, Michele; Andreola, Salvatore; Collini, Federica; Gentile, Guendalina; Maciocco, Francesca; Maghin, Francesca; Zoja, Riccardo
Histochemical determination of lead in gunshot residues (GSR) raises the question of possible environmental contamination by heavy metals. Authors assess the specificity of the Sodium Rhodizonate Test in the search of lead derived from environmental pollution. Sodium Rhodizonate Test and 5% HCl Sodium Rhodizonate test were applied to skin samples taken from two groups of victims, whose cause of death was not related to gunshot wounds: group A included 25 corpses found in open spaces after a long time; group B included 16 corpses exhumed after a period of 11 years. The use of these histochemical tests to skin samples from these two groups did not show metal debris histochemically similar to the lead present in GSR. These tests were confirmed to be specific in highlighting the GSR coming from gunshot, without being affected by the potential environmental contamination of the heavy metal pollutants, coming from air or soil. Copyright © 2017 Elsevier B.V. All rights reserved.
Li, Ronggang; Liu, Xingyan; Chen, Keming; Ye, Jianjun; Gao, Mingxuan; Ge, Baofeng; Wang, Yong; Xiong, Faming; Liang, Jianping
Gunshot wound spreads to the surrounding tissues and organs, it is difficult to debride and easy to infect. The conventional treatment is thorough, extensive debridement, fully open drainage, which often causes normal tissue damage and complications. To evaluate the effectiveness of vacuum sealing drainage (VSD) treating the penetrating wound in porcine extremity by MRI and pathological methods so as to provide theoretical basis for future clinical use. Eight healthy adult pigs, weighing (45 +/- 5) kg, were selected. Eight pairs of hind limb penetrating wounds (16 wounds) were made by using Chinese-made 95-type rifle at 25 meters distance, which were randomly divided into experimental group (left side, n=8) and the control group (right side, n=8). After debriding and disinfecting the penetrating wounds at 6 hours after injury, wounds were treated with VSD in experimental group. The ballistics exports of the wounds were covered with single-layer gauze and imports were directly sutured and covered with sterile gauze in control group. The trajectory and the general condition of the adjacent skin were observed. MRI and histological observation were taken at 5, 24, 48, and 72 hours after injury, bacterial counting analysis was done at 0, 12, 24, 48, and 72 hours after injury. The aperture of the trajectory exit and entry were (5.00 +/- 2.50) cm and (0.30 +/- 0.15) cm immediately after injury. The wound surface was clean, rosy without leakage and swelling after 72 hours in experimental group; wound and adjacent tissue were swelling obviously, pus, muscle necrosis and exfoliative tissue was observed, and deep defect cavity at the trajectory exit could be seen in control group. MRI showed that pairs of linear low signal in T1WI and T2WI was seen in trajectory of experimental group at 5 hours after injury, and signal in T1WI gradually increased at disrupted area and tissue deformation area at 24, 48, and 72 hours; in control group, low signal in T1WI was observed at 5 hours
Blanes, Lucas; Cole, Nerida; Doble, Philip; Roux, Claude
In recent years, forensic scientists have become increasingly interested in the detection and interpretation of organic gunshot residues (OGSR) due to the increasing use of lead- and heavy metal-free ammunition. This has also been prompted by the identification of gunshot residue- (GSR-) like particles in environmental and occupational samples. Various techniques have been investigated for their ability to detect OGSR. Mass spectrometry (MS) coupled to a chromatographic system is a powerful tool due to its high selectivity and sensitivity. Further, modern MS instruments can detect and identify a number of explosives and additives which may require different ionization techniques. Finally, MS has been applied to the analysis of both OGSR and inorganic gunshot residue (IGSR), although the “gold standard” for analysis is scanning electron microscopy with energy dispersive X-ray microscopy (SEM-EDX). This review presents an overview of the technical attributes of currently available MS and ionization techniques and their reported applications to GSR analysis. PMID:24977168
Ozdemir, Mevci; Unlü, Ağahan
Traditional shooting with guns often occurs and leads to unwanted gunshot injuries in areas where celebrations are held. Such injuries have been classified as celebratory gun shooting injury in the international disease classification system. An 8-year-old female patient presented with respiratory arrest. The heartbeats normalized upon cardiopulmonary resuscitation. On physical examination, the only pathological finding was a skin defect measuring 1 x 1 cm on the midline and located 2 cm in front of the coronal suture. Cranial CT revealed a bone defect of 0.5 cm in the area 2 cm in front of the coronal suture on the midline, tetraventricular and extensive subarachnoid hemorrhage and parenchymal hematoma in the frontal area. It was initially thought to be a gunshot injury; however, on cranial CT, no bullet fragments or bullet exit hole was observed. A cervicothoracal direct graph was obtained and an image that might have been compatible with a bullet core was detected at Th 2-3 vertebra level. Although gunshot injuries are generally well- known, this may not be a very familiar topic for neurosurgeons. The primary aim of this report is to emphasize that a bullet round randomly fired into the air ascends in reverse direction to gravity and after reaching a zero point, it returns to the ground at a high velocity that facilitates its penetration into the skull according to a principal physics law.
Migliorini, Arnaldo Stanislao; Andreola, Salvatore; Battistini, Alessio; Gentile, Guendalina; Muccino, Enrico; Vancheri, Giulia; Zoja, Riccardo
The application of the histochemical stain of sodium rhodizonate to the entrance wound for the detection of the lead (Pb) residues coming from the gunshot may be affected by false positive cases due to the contamination of the environmental Pb. The aim of the Authors is to histochemically search the Pb of GSR in a region which should be more protected by the contamination: the intracorporeal channel. Two hundreds and eighteen serial histological specimens of the intracorporeal channels coming from 25 subjects (dead due to gunshots and being autopsied at the Section of Legal Medicine of the Milan University, in the years 2013-2014) were stained with the sodium rhodizonate and sodium rhodizonate in acid environment (HCl 5%), and then observed by the microscope. The sodium rhodizonate showed a positivity for the Pb residues in the intracorporeal channel, with the detection of the particles within the first 2 cm beyond the entrance wound in 6 cases over the total number of 25 (24%). Victims were characterized by common features: short-barreled weapon; contact shots or short-distance shots; involvement of regions that were not covered by clothing; preservation of the microscopic structure of organs interested by the intracorporeal channel. The searching of GSR in the intracorporeal channel, even in conditions securing a high sensitivity, could represent an important test for the discrimination between an environmental contamination of Pb and the presence of Pb residues by GSR: once confirmed the presence of GSR in the intracorporeal channel by the histochemical analysis, the diagnostic process should require the application of the SEM-EDX for the confirmation of the results. Although not yet studied, this combination could be applied to cadavers exposed to the environment, with advanced post-mortal phenomena permitting at least the suspects of the existence of gunshot wounds at the macroscopic autopsy evaluation. Indeed, in some cases, the putrefaction is so advanced
Bolliger, Stephan A; Thali, Michael J; Bolliger, Michael J; Kneubuehl, Beat P
By measuring the total crack lengths (TCL) along a gunshot wound channel simulated in ordnance gelatine, one can calculate the energy transferred by a projectile to the surrounding tissue along its course. Visual quantitative TCL analysis of cut slices in ordnance gelatine blocks is unreliable due to the poor visibility of cracks and the likely introduction of secondary cracks resulting from slicing. Furthermore, gelatine TCL patterns are difficult to preserve because of the deterioration of the internal structures of gelatine with age and the tendency of gelatine to decompose. By contrast, using computed tomography (CT) software for TCL analysis in gelatine, cracks on 1-cm thick slices can be easily detected, measured and preserved. In this, experiment CT TCL analyses were applied to gunshots fired into gelatine blocks by three different ammunition types (9-mm Luger full metal jacket, .44 Remington Magnum semi-jacketed hollow point and 7.62 × 51 RWS Cone-Point). The resulting TCL curves reflected the three projectiles' capacity to transfer energy to the surrounding tissue very accurately and showed clearly the typical energy transfer differences. We believe that CT is a useful tool in evaluating gunshot wound profiles using the TCL method and is indeed superior to conventional methods applying physical slicing of the gelatine.
Amadasi, Alberto; Gibelli, Daniele; Mazzarelli, Debora; Porta, Davide; Gaudio, Daniel; Salsarola, Dominic; Brandone, Alberto; Rizzi, Agostino; Cattaneo, Cristina
In case of gunshot wounds, forensic anthropologists and pathologists have many tools at hand, and the assistance that chemical and microscopic investigations can provide in such scenarios is often valuable and crucial. However, the results of such analyses in the search of gunshot residues (GSR) ought not to be acritically considered. We report five cases where chemical (sodium rhodizonate) and microscopic (scanning electron microscopy-energy dispersive X-ray spectroscopy (SEM-EDX)) analyses were performed for the search of GSR. Four cases concerned the forensic field and analyses on buried, charred, or submerged remains, whereas one case concerned the historical remains of a soldier of the First World War. In every case, the search for GSR with these techniques showed their persistence even after long periods and preservation in peculiar environments. However, chemical analyses provided their contribution, but in two cases, anthropological analyses provided crucial and solving results. The five cases show the indisputable usefulness of chemical and microscopic analyses in the search of GSR in gunshot wounds and especially how such residues may survive in time and in adverse environmental conditions. However, experts should always be dubious about some pitfalls (such as contamination) one can frequently find in these scenarios.
Peritoneal tap; Paracentesis; Ascites - abdominal tap; Cirrhosis - abdominal tap; Malignant ascites - abdominal tap ... abdominal cavity ( most often cancer of the ovaries ) Cirrhosis of the liver Damaged bowel Heart disease Infection ...
Buszewska-Forajta, Magdalena; Siluk, Danuta; Struck-Lewicka, Wiktoria; Raczak-Gutknecht, Joanna; Markuszewski, Michał J; Kaliszan, Roman
In recent years biologically active compounds isolated from insects call special interest of drug researchers. According to some Polish etnopharmacological observations, secretion from the grasshopper's abdomen (Orthoptera family) is believed to speed up the process of wound healing. In the present work we focused on determination of main components of the lipid fraction of material from grasshopper abdomen using GC-MS/MS. Samples were qualitatively analyzed using gas chromatography coupled with mass spectrometry. Both liquid-liquid extraction and solid-phase extraction pretreatment methods were used to concentrate and fractionate the compounds from the insect. In the derivatized fractions ca. 350 compounds were identified, including substances of known biological activity. The potential agents affecting wound healing have been indicated. A set of compounds characteristic for all the studied Chorthippus spp., have been identified. Data analysis revealed different lipidomic profiles of grasshoppers depending on the insects origin and collection area. Copyright © 2013 Elsevier B.V. All rights reserved.
Strajina, Veljko; Živković, Vladimir; Nikolić, Slobodan
This study presents a case series of suicides carried out by self-inflicted gunshot wounds to the chest-a relatively uncommon means of suicide. The retrospective autopsy study performed included all cases of single suicidal gunshot injuries to the chest during a 20-year period and which were committed by the use of a handgun. The sample included 67 deceased persons that were an average of 44.4 ± 19.1 years old (range, 12-89 years; 58 men and 9 women). The most common region of the entrance wound was the left side of the chest (54/67), followed by the sternum (10/67), and the right side of the chest (3/67). For 9 subjects, the range of fire could not be determined, as well as whether the shot went through their clothing. In the remaining 58 subjects, only contact or near-contact wounds were found. Of the 58, only 3 subjects had their clothing removed between the chest wall and the muzzle. Three directions of the internal bullet paths were those most frequently found: downward right-to-left (27/67), downward left-to-right (20/67), and downward parallel (10/67) (χ = 101.045, P = 0.000). Also, most bullet paths were directed downward (57/67, χ = 32.970, P = 0.000). The most frequently injured organ was the heart (47/67), and the immediate causes of death were exsanguination (49/67), heart disruption (14/67), and tamponade (4/67).
Guruprasad, Yadavalli; Giraddi, Girish
An unusual case of facial gunshot injury with the missile lodged in the cervical spine region, but without any neurological impairment, is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by computed tomography scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for one year. We present a case of gunshot injury to the face with the missile lodged in the cervical spine region and atypical absence of clinical manifestation that may occur even when a bullet remains in the vicinity of the cervical spine. PMID:21915384
Smith, Edward Reed; Shapiro, Geoff; Sarani, Babak
The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy. A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity. The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries. Prognostic/epidemiologic study, level IV
Bumbasirević, M; Lesić, A; Bumbasirević, V; Rakocević, Z; Djurić, M
An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.
Wu, Si-Yu; Hu, Wei; Zhang, Bo; Liu, Shuai; Wang, Jian-Min; Wang, Ai-Min
In a previous study, we proposed a new therapy using topical bromelain as a supplement to simple wound-track incision for the debridement of firearm wounds. This enzymatic debridement greatly simplified the management of high-velocity gunshot wounds in a pig model, and bromelain was confirmed to improve wound healing. The purpose of the present study was to investigate the effect of bromelain on the microenvironment of firearm wounds. Sixteen Chinese landrace pigs wounded by high-velocity projectiles were divided randomly into four groups: wound incision (group I), incision + bromelain (group IB), wound excision (group E), and control. Blood perfusion, oxygen partial pressure (pO(2)), and the content of tumor necrosis factor (TNF)-α and transforming growth factor (TGF)-β in wound-track tissue were measured. Wound healing was also noted. The recovery of blood perfusion in tissue and pO(2) in wound tracks was significantly more rapid in group IB and group E than in group I and control. The tissue level of TNF-α was significantly lower in group IB than in group I and control 48 h and 72 h post-wounding, and was lower than in group E 48 h post-wounding. The tissue level of TGF-β in group IB was sustained at a significantly higher level than in the other three groups. Wound healing time was also shorter in group IB. Enzymatic debridement using topical bromelain in incised wound tracks accelerates the recovery of blood perfusion, pO(2) in wound tissue, controls the expression of TNF-α and raises the expression of TGF-β. Copyright © 2012 Elsevier Inc. All rights reserved.
Tokdemir, Mehmet; Kafadar, Huseyin; Turkoglu, Abdurrahim; Bork, Turgay
Multiple entrance gunshot wounds can give useful information in forensic evaluation of deaths from homicide and suicide. Although the presence of multiple entrance gunshot wounds does not absolutely exclude the possibility of suicide, they are important to the forensic investigators and pathologists in cases of assault, attempted homicide and suicide as they provide important clues for determination of number of shots fired and direction of firing. We present a case of 16 years of young woman who was shot to death by her husband. External examination revealed an entrance wound with semi-lunar shot residue at the dorsal side of her left hand at 5th metacarpus, and exit wound on the hypothenar muscle. There was also a second wound entrance located on her left zygoma. Direction of the bullet was downward traveling from left-to-right. Initially it was thought that there were two close shots, but when her left hand was placed over the malar area her face, it was determined that the gunshot powder tattoos were completing the nature of a single shot from a close distance. Crime scene investigation revealed only one cartridge casing. The autopsy and radiography findings showed that the bullet was entered from dorsal site of the left hand exiting from the palm and re-entering from the zygomatic region, hit the base of the skull, and remained in the soft tissue of the right mandible after passing the soft palate. The bullet was caused an incomplete laceration of the right internal arteria carotid and she died of internal and external bleeding. Detailed investigation of gunshot residues can provide important information for clarification of close distance gunshot wounding. We present this case due to its interesting nature, and to highlight the importance of detailed investigation of the gun powder residues in cases with multiple entry wounds.
Prat, N J; Daban, J-L; Voiglio, E J; Rongieras, F
Wounds due to gunshot and explosions, while usually observed during battlefield combat, are no longer an exceptional occurrence in civilian practice in France. The principles of wound ballistics are based on the interaction between the projectile and the human body as well as the transfer of energy from the projectile to tissues. The treatment of ballistic wounds relies on several principles: extremity wound debridement and absence of initial closure, complementary medical treatment, routine immobilization, revision surgery and secondary closure. Victims of explosions usually present with a complex clinical picture since injuries are directly or indirectly related to the shock wave (blast) originating from the explosion. These injuries depend on the type of explosive device, the environment and the situation of the victim at the time of the explosion, and are classed as primary, secondary, tertiary or quaternary. Secondary injuries due to flying debris and bomb fragments are generally the predominant presenting symptoms while isolated primary injuries (blast) are rare. The resulting complexity of the clinical picture explains why triage of these victims is particularly difficult. Certain myths, such as inevitable necrosis of the soft tissues that are displaced by the formation of the temporary cavitation by the projectile, or sterilization of the wounds by heat generated by the projectile should be forgotten. Ballistic-protective body armor and helmets are not infallible, even when they are not perforated, and can even be at the origin of injuries, either due to missile impact, or to the blast. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
De Forest, Peter R; Martir, Kirby; Pizzola, Peter A
The velocity of over 800 gunshot residue particles from eight different sources was determined using high speed stroboscopic photography (spark gap light source). These particles were found to have an average velocity of 500 to 600 ft per second. Many particles acquired considerably higher velocities. Thus, the particles have sufficient energy to embed themselves within certain nearby targets like skin or fabric. The relatively high velocity that the particles acquire explain the formation of stippling on skin in close proximity to a muzzle discharge. These findings also indicate little influence of air currents on particle behavior near the muzzle. The deceleration of less than 100 particles during a 100-microsecond interval was also calculated. The particles experienced rapid rates of deceleration which would explain why few particles are found in test firings beyond 3 ft from the muzzle of a discharged firearm. Because of their relatively high velocity, normal wind velocity would not be expected to significantly influence their motion near the muzzle.
López R., Juan Manuel; Marulanda B., Jose Ignacio
This work presents a prototype of low-cost gunshots identification system that uses consumer electronics in order to ensure the existence of gunshots and then classify it according to a previously established database. The implementation of this tool in the urban areas is to set records that support the forensics, hence improving law enforcement also on developing countries. An analysis of its effectiveness is presented in comparison with theoretical results obtained with numerical simulations.
Maurya, Sanjay; Bhandari, Prem Singh
Significance: Wounds sustained in a combat trauma often result in a composite tissue loss. Combat injuries, due to high energy transfer to tissues, lead to trauma at multiple anatomical sites. An early wound cover is associated with lower rate of infections and a faster wound healing. The concept of negative pressure wound therapy (NPWT) in the management of combat-related wounds has evolved from the civilian trauma and the wounds from nontraumatic etiologies. Recent Advances: Encouraged by the results of NPWT in noncombat-related wounds, the military surgeons during Operation Iraqi Freedom and Operation Enduring Freedom used this novel method in a large percentage of combat wounds, with gratifying results. The mechanism of NPWT in wound healing is multifactorial and often complex reconstructive procedure can be avoided in a combat trauma setting. Critical Issues: Wounds sustained in military trauma are heavily contaminated with dirt, patient clothing, and frequently associated with extensive soft tissue loss and osseous destruction. Delay in evacuation during an ongoing conflict carries the risk of systemic infection. Early debridement is indicated followed by delayed closure of wounds. NPWT helps to provide temporary wound cover during the interim period of debridement and wound closure. Future Directions: Future area of research in combat wounds is related to abdominal trauma with loss of abdominal wall. The concept of negative pressure incisional management system in patients with a high risk of wound breakdown following surgery is under review, and may be of relevance in combat wounds. PMID:27679749
Maurya, Sanjay; Bhandari, Prem Singh
Significance: Wounds sustained in a combat trauma often result in a composite tissue loss. Combat injuries, due to high energy transfer to tissues, lead to trauma at multiple anatomical sites. An early wound cover is associated with lower rate of infections and a faster wound healing. The concept of negative pressure wound therapy (NPWT) in the management of combat-related wounds has evolved from the civilian trauma and the wounds from nontraumatic etiologies. Recent Advances: Encouraged by the results of NPWT in noncombat-related wounds, the military surgeons during Operation Iraqi Freedom and Operation Enduring Freedom used this novel method in a large percentage of combat wounds, with gratifying results. The mechanism of NPWT in wound healing is multifactorial and often complex reconstructive procedure can be avoided in a combat trauma setting. Critical Issues: Wounds sustained in military trauma are heavily contaminated with dirt, patient clothing, and frequently associated with extensive soft tissue loss and osseous destruction. Delay in evacuation during an ongoing conflict carries the risk of systemic infection. Early debridement is indicated followed by delayed closure of wounds. NPWT helps to provide temporary wound cover during the interim period of debridement and wound closure. Future Directions: Future area of research in combat wounds is related to abdominal trauma with loss of abdominal wall. The concept of negative pressure incisional management system in patients with a high risk of wound breakdown following surgery is under review, and may be of relevance in combat wounds.
... into the wound during a puncture, along with dirt and debris from the object. All puncture wounds ... object, such as a rusty nail, the more dirt and debris are dragged into the wound, increasing ...
Duran, Latif; Kayhan, Servet; Kati, Celal; Akdemir, Hizir Ufuk; Balci, Kemal; Yavuz, Yucel
Cerebral fat embolism syndrome is a lethal complication of long-bone fractures and clinically manifasted with respiratory distress, altered mental status, and petechial rash. We presented a 20-year-old male admitted with gun-shot wounds to his left leg. Twenty-four hours after the event, he had generalized tonic clonic seizures, decorticate posture and a Glascow Coma Scale of seven with localization of painful stimuli. Subsequent magnetic resonance imaging of the brain showed a star-field pattern defining multiple lesions of restricted diffusion. On a 4-week follow-up, he had returned to normal neurological function. Despite the severity of the neurological condition upon initial presentation, the case cerebral fat embolism illustrates that, cerebral dysfunction associated with cerebral fat embolism illustrates reversible.
Duran, Latif; Kayhan, Servet; Kati, Celal; Akdemir, Hizir Ufuk; Balci, Kemal; Yavuz, Yucel
Cerebral fat embolism syndrome is a lethal complication of long-bone fractures and clinically manifasted with respiratory distress, altered mental status, and petechial rash. We presented a 20-year-old male admitted with gun-shot wounds to his left leg. Twenty-four hours after the event, he had generalized tonic clonic seizures, decorticate posture and a Glascow Coma Scale of seven with localization of painful stimuli. Subsequent magnetic resonance imaging of the brain showed a star-field pattern defining multiple lesions of restricted diffusion. On a 4-week follow-up, he had returned to normal neurological function. Despite the severity of the neurological condition upon initial presentation, the case cerebral fat embolism illustrates that, cerebral dysfunction associated with cerebral fat embolism illustrates reversible. PMID:24701067
Moreira, Maria E; Markovchick, Vincent J
Wound management makes up an important part of the emergency physician's practice. Understanding the physiology of wound healing and the patient and wound factors affecting this process is essential for the proper treatment of wounds. There are many options available for wound closure. Each modality has its benefits and its drawbacks, and some are appropriate only for certain types of wounds. The goal is to achieve the best functional and cosmetically appealing scar while avoiding complications.
Ashindoitiang, J A; Atoyebi, A O; Arogundade, R A
The plain abdominal x-ray is still the first imaging modality in diagnosis of acute abdomen. The aim of this study was to find the value of plain abdominal x-ray in the management of abdominal emergencies seen in Lagos university teaching hospital. The accurate diagnosis of the cause of acute abdominal pain is one of the most challenging undertakings in emergency medicine. This is due to overlapping of clinical presentation and non-specific findings of physical and even laboratory data of the multifarious causes. Plain abdominal radiography is one investigation that can be obtained readily and within a short period of time to help the physician arrive at a correct diagnosis The relevance of plain abdominal radiography was therefore evaluated in the management of abdominal emergencies seen in Lagos over a 12 month period (April 2002 to March 2003). A prospective study of 100 consecutively presenting patients with acute abdominal conditions treated by the general surgical unit of Lagos University Teaching Hospital was undertaken. All patients had supine and erect abdominal x-ray before any therapeutic intervention was undertaken. The diagnostic features of the plain films were compared with final diagnosis to determine the usefulness of the plain x-ray There were 54 males and 46 females (M:F 1.2:1). Twenty-four percent of the patients had intestinal obstruction, 20% perforated typhoid enteritis; gunshot injuries and generalized peritonitis each occurred in 13%, blunt abdominal trauma in 12%, while 8% and 10% had acute appendicitis and perforated peptic ulcer disease respectively. Of 100 patients studied, 54% had plain abdominal radiographs that showed positive diagnostic features. Plain abdominal radiograph showed high sensitivity in patients with intestinal obstruction 100% and perforated peptic ulcer 90% but was less sensitive in patients with perforated typhoid, acute appendicitis, and blunt abdominal trauma and generalized peritonitis. In conclusion, this study
Gameiro, Vinicius Schott; de Araújo, Gabriel Costa Serrão; Bruno, Felipe Motta Moreira
This case is of a man who suffered gunshots and developed saturnism. Projectiles were removed from the abdomen, but one was left in the knee for 14 years. The patient presented with weight loss, headaches, loss of sight, tiredness, cramps, painful joints and trembling. We identified ataxic movements such as intense trembling of the limbs and anaemia. The abdominal pain caused eight internments in different hospitals, and the patient always received the diagnosis of intestinal subocclusion. We removed the bullet and did a wide synovectomy. The patient did not receive a clinical treatment with chelates. The symptoms of lead poisoning ceased, but he developed knee osteoarthritis, during the 7 years of follow-up.
Ongom, Peter A; Kijjambu, Stephen C; Jombwe, Josephat
Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet's trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering'; a first of its kind in East Africa. A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering') of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering' bullet was successfully removed surgically. It had caused no damage to any part of her neck structure. AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the
Wound healing in orthopaedic care is affected by the causes of the wound, as well as concomitant therapies used to repair musculoskeletal structures. Promoting the health of the host and creating an environment to foster natural healing processes is essential for helping to restore skin integrity. Normal wound healing physiologic processes, factors affecting wound healing, wound classification systems, unique characteristics of orthopaedic wounds, wound contamination and drainage characteristics, and potential complications are important to understand in anticipation of patient needs. Accurate wound assessment and knowledge of nursing implications with specific wound care measures (cleansing, debridement, and dressings) is important for quality care. New technologies are enhancing traditional wound care measures with goals of effective comfortable wound care to promote restoration of skin integrity.
Baraybar, Jose Pablo
The analysis of the distribution of gunshot injuries in a sample of 777 sets of human remains of proven human rights abuse from Somaliland, the Balkans and Peru is compared to frequencies of injuries sustained by combatants in contemporary conflicts reported in the literature. Principal Component Analysis (PCA) reduced the data to three components accounting for 82.94% of the variance. The first component with 38.31% of variance shows segments Arms and thorax/abdomen to be positively correlated (0.887 and 0.662, respectively); the segment head/neck is strongly correlated (0.951) to the second component while the segment thorax/abdomen shows a low, negative correlation (-0.388). Finally in the third component only the legs are strongly correlated (0.991). Data was further subjected to a K-means cluster analysis to determine the likely groupings combining the four types of injuries. Each of the three clusters reproduced similar patterns observed in the PCA: Cluster 1 shows the prevalence of injuries to the thorax/abdomen and extremities in addition to injuries to the head/neck; Cluster 2 shows injuries to the head/neck and Cluster 3 injuries to the thorax/abdomen and a lower representation of the arms and legs. Most of the cases (70.5%), irrespective of geography and type of site (attack or detention), were grouped into Cluster 2. Such comparison shows that in human rights abuse, irrespective of their geography, gunshot injuries tend to follow a pattern favouring the head/neck and thorax/abdomen areas over the extremities, the reverse pattern observed in contemporary combat operations. In those settings gunshot wound trauma is the second cause of mortality/morbidity (after fragmenting ammunition) and its distribution concentrates on the extremities, thorax/abdomen and head; following the pattern of protective armour when it is used. Considering that human rights abuses are often presented as encounters between two armed groups in the context of counter
Samokhvalov, I M; Reva, V A; Denisov, A V; Ozeretskovskiĭ, L B; Pronchenko, A A
The aim of the given study was development of surgical tactics in case of femoral artery injury, caused by medium-calibre bullet, on the basis acute experiment on large biological objects. Experimental animals were shot into mid third of the femora by a rifle cartridge in 7,62-mm calibre (AK-47 made in 1943). The analysis of microstructure, made in 5 cross-sections performed every 1-centimetre way from the wound canal, showed that there were no any damages of arterial wall. Authors came to conclusion that the surgical debridement of the gunshot wound, made by a rifle cartridge in 7,62-mm calibre of AK-47, should consist of exsection of devitalized section of artery.
Alvis-Miranda, Hernando Raphael; Adie Villafañe, Roberto; Rojas, Alejandro; Alcala-Cerra, Gabriel
Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive. PMID:27169063
Gordon, D S
The patient with a cerebral gunshot wound has a very unstable condition. In Belfast emphasis has been laid on rapid evacuation and on starting resuscitation within a few minutes of injury. Early and adequate transfusion combats shock; controlled ventilation helps limit the rise in intracranial pressure. Intracranial haematomata should be sought by early operation. Operation seldom improves neurological function in missile wounds of the spine. PMID:1125629
Molina, D Kimberley; Martinez, Michael; Garcia, James; DiMaio, Vincent J M
Several different methods can be employed to test for gunshot residue (GSR) on a deceased person's hands, including scanning electron microscopy with energy-dispersive x-ray spectroscopy (SEM-EDX) and inductively coupled plasma-atomic emission spectrometry (ICP-AES). Each of these techniques has been extensively studied, especially on living individuals. The current studies (Part I and Part II) were designed to compare the use and utility of the different GSR testing techniques in a medical examiner setting. In Part I, the hands of deceased persons who died from undisputed suicidal handgun wounds were tested for GSR by SEM-EDX over a 4-year period. A total of 116 cases were studied and analyzed for caliber of weapon, proximity of wound, and results of GSR testing, including spatial deposition upon the hands. It was found that in only 50% of cases with a known self-inflicted gunshot wound was SEM-EDX positive for at least 1 specific particle for GSR. In 18% of the cases there was a discernible pattern (spatial distribution) of the particles on the hand such that the manner in which the weapon was held could be determined. Since only 50% of cases where the person is known to have fired a weapon immediately prior to death were positive for GSR by SEM-EDX, this test should not be relied upon to determine whether a deceased individual has discharged a firearm. Furthermore, in only 18% of cases was a discernible pattern present indicating how the firearm was held. The low sensitivity, along with the low percentage of cases with a discernible pattern, limits the usefulness of GSR test results by SEM-EDX in differentiating self-inflicted from non-self-inflicted wounds.
Riou, J P; Cohen, J R; Johnson, H
Thirty-one abdominal fascial wound dehiscences occurred in 2,761 patients undergoing major abdominal surgery during a 5-year period (1%). Twenty-two specific local and systemic risk factors were analyzed and compared with the risk factors of a control group of 38 patients undergoing similar procedures without dehiscence. Through multivariate analysis, each factor was assessed as an independent statistical variable. Significant factors (p less than 0.05) were found to include age over 65, wound infection, pulmonary disease, hemodynamic instability, and ostomies in the incision. Additional systemic risk factors that were found to be significant included hypoproteinemia, systemic infection, obesity, uremia, hyperalimentation, malignancy, ascites, steroid use, and hypertension. Risk factors not found to be important independent variables included sex, type of incision, type of closure, foreign body in the wound, anemia, jaundice, and diabetes. When dehiscence and control groups were combined, 30% of patients with at least five significant risk factors developed dehiscence, and all the patients with more than eight risk factors developed a wound dehiscence. There was an overall mortality of 29%, which was directly related to the number of significant risk factors. The co-existence of 9 risk factors portended death in one third of the patients, and all the patients with more than 10 risk factors died.
Molina, D Kimberley; Castorena, Joe L; Martinez, Michael; Garcia, James; DiMaio, Vincent J M
Several different methods can be employed to test for gunshot residue (GSR) on a decedent's hands, including scanning electron microscopy with energy dispersive x-ray (SEM/EDX) and inductive coupled plasma-atomic emission spectrometry (ICP-AES). In part I of this 2-part series, GSR results performed by SEM/EDX in undisputed cases of suicidal handgun wounds were studied. In part II, the same population was studied, deceased persons with undisputed suicidal handgun wounds, but GSR testing was performed using ICP-AES. A total of 102 cases were studied and analyzed for caliber of weapon, proximity of wound, and the results of the GSR testing. This study found that 50% of cases where the deceased was known to have fired a handgun immediately prior to death had positive GSR results by ICP/AES, which did not differ from the results of GSR testing by SEM/EDX. Since only 50% of cases where the person is known to have fired a weapon were positive for GSR by either method, this test should not be relied upon to determine whether someone has discharged a firearm and is not useful as a determining factor of whether or not a wound is self-inflicted or non-self-inflicted. While a positive GSR result may be of use, a negative result is not helpful in the medical examiner setting as a negative result indicates that either a person fired a weapon prior to death or a person did not fire a weapon prior to death.
Fritz, Deborah; Weilitz, Pamela Becker
Abdominal pain is one of the most common complaints by patients, and assessment of abdominal pain and associated symptoms can be challenging for home healthcare providers. Reasons for abdominal pain are related to inflammation, organ distention, and ischemia. The history and physical examination are important to narrow the source of acute or chronic problems, identify immediate interventions, and when necessary, facilitate emergency department care.
Hoppe, Ian C; Kordahi, Anthony M; Paik, Angie M; Lee, Edward S; Granick, Mark S
Facial fractures are relatively uncommon in the pediatric population, especially those inflicted as a result of interpersonal violence in the form of gunshot injuries. Few studies have examined the unique management of such high-energy injuries in the pediatric population. Oftentimes the resultant damage to soft tissue and bony structures is so great that it challenges the previously accepted standards in the management of pediatric facial fractures. This study will examine a level 1 trauma center's experience with these unique injuries. A retrospective review of all facial fractures occurring in a pediatric population (those 18 years of age or younger) as a result of gunshot wounds in a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Descriptive information was collected regarding each case as well as information regarding concomitant injuries, treatment modalities, and selected outcomes. During this time period, there were 3147 facial fractures treated at our institution, 353 of which were in pediatric patients. Of these, 17 were the results of gunshot wounds. Three patients were excluded due to insufficient data, leaving a total of 14 patients. The average age of patients was 16.5 (range 14-18); all patients were African-American males. The most common fracture was that of the mandible (n = 10), with 2 of those patients exhibiting panfacial fractures. The average Glasgow Coma Scale on admission was 13.5 (range 3-15). Six of the patients were intubated in the emergency department. The most common concomitant injury was a skull fracture (n = 3), followed by cervical spine fractures (n = 2) and intracranial hemorrhages (n = 2). All patients were admitted to the hospital for reasons other than fracture management. Seven patients ultimately went to the operating room for fracture management. The treatment modalities employed were conservative management with closed techniques (n = 11), rigid internal fixation (n = 2), and the
Korohl, S O; Zherdev, I I; Domanskiy, A M
Experience of medical sorting of 434 injured persons with a gun-shot woundings of extremities in 2014-2015 yrs is adduced. The principles of organization and treatment for medical sorting of wounded persons were elaborated. Prognostic intrahospital, diagnostic and evacuation--transport sorting was introduced in wounded persons in the IV level hospital, concerning severity of traumatic shock and prognosis of their survival.
Mansor, Salah; Bodalal, Zuhir
To analyze the impact of the method of Gunshot Injury (GSI) (i.e. war injuries, stray bullets, and civilian fighting) on patient morbidity and mortality. An observational study. Biostatistics Department of Al-Jalaa Hospital in Benghazi, Libya, from January to December 2011. Patients' records were analyzed with the method of gunshot injury as a classifying/comparative parameter. Age, gender, site of injury, receiving department, ICU admission, city of origin, length of stay, morbidity and mortality were determined and compared between the different methods of GSI. During the conflict, 1761 gunshot injuries were treated at the hospital. The method of injury was recorded for 62% (n=1096) of the cases and were classified under war injuries (72.2%, n=791), stray bullets (14.1%, n=155), and civilian fighting (13.7%, n=150). Nearly all the patients being treated for civilian fighting (98%, n=147) were males, (stray bullets, 82.6%, n=128, and war injuries 98.4%, n=778). Women were significantly less involved in a war injury (1.6%, n=13, p < 0.001). Stray bullets affected the younger age groups i.e. ² 19 years (26.5%, n=41) more than either fighting injuries (8%, n=12) or war injuries (11.8%, n=93, p < 0.001). Civilian fighting injuries (83.3%, n=125) mostly involved the 20-39 years age group (p < 0.001). Fighting wounds and stray bullets were more common in an urban (82.7%, n=124) rather than rural setting (p < 0.001); the same was true for stray bullets (76.8%, n = 119). The number of GSI's showed a close relationship with major events in society (i.e. military campaigns, celebration and civilian unrest). Significantly higher mortality rates were observed in civilian fighting injuries (7.7%, n=12, p=0.003) and stray bullets (10%, n=15, p=0.003) compared to general GSI's (5.2%, n=91) and war injuries (4.4%, n=35). Surgeons and general physicians need to be aware that GSI's differ in their salient features and outcome based on the method of injury.
Because of the enhanced intracranial tissue disruption (see companion paper) and the functional significance of the central nervous system, penetrating gunshot wounds of the head commonly result in immediate incapacitation. However, in the last century numerous publications reported sustained capability to act following penetrating gunshot wounds of the head. These are reviewed. A large number of case reports had to be excluded from re-examination because of doubtful capability to act or lack of morphological documentation. There remained 53 case reports from 42 sources for systematic analysis. Favourable conditions for sustained capability to act are present in cases where the additional wounding resulting from the special wound ballistic qualities of the head (see companion paper) are minimized. Thus, more than 70% of the guns used fired slow and lightweight bullets: 6.35 mm Browning, .22 rimfire or extremely ineffective projectiles (ancient, inappropriate or selfmade). A centre-fire rifle or a shotgun from close range were never employed in cases involving intracerebral tracts. A coincidence of several lucky circumstances made sustained capability to act possible in two cases of military centrefire rifle bullets passing longitudinally between the frontal lobes without direct contact with brain tissue. Only two large handguns resulting in intracerebral wounding were used: one firing a .38 special bullet, which solely wounded the base of the right temporal lobe and one firing a .45 lead bullet, which seriously injured the left frontal lobe but whose trajectory was limited to the anterior fossa of the skull. Of the trajectories, 28% were outside the neurocranium. At least 70% of the craniocerebral tracts passed above the anterior fossa of the skull, wounding the frontal parts of the brain. Apart from a neurophysiological approach, this preference can be explained by the fact that the base of the anterior cranial fossa and the sella turcica area serve as a bony
Lazarjan, Milad Soltanipour; Geoghegan, Patrick Henry; Jermy, Mark Christopher; Taylor, Michael
The mechanical properties of the human brain at high strain rate were investigated to analyse the mechanisms that cause backspatter when a cranial gunshot wound occurs. Different concentrations of gelatine and a new material (M1) developed in this work were tested and compared to bovine brain samples. Kinetic energy absorption and expansion rate of the samples caused by the impact of a bullet from .22 air rifle (AR) (average velocity (uav) of 290m/s) and .22 long rifle (LR) (average velocity (uav) of 330m/s) were analysed using a high speed camera (24,000fps). The AR projectile had, in the region of interest, an average kinetic energy (Ek) of 42±1.3J. On average, the bovine brain absorbed 50±5% of Ek, and the simulants 46-58±5%. The Ek of the .22 LR was 141±3.7J. The bovine brain absorbed 27% of the .22LR Ek and the simulants 15-29%. The expansion of the sample, after penetration, was measured. The bovine brain experienced significant plastic deformation whereas the gelatine solution exhibited a principally elastic response. The permanent damage patterns in the M1 material were much closer to those in brain tissue, than were the damage patterns in the gelatine. The results provide a first step to developing a realistic experimental simulant for the human brain which can produce the same blood backspatter patterns as a human brain during a cranial gunshot. These results can also be used to improve the 3D models of human heads used in car crash and blast trauma injury research. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Vogel, H; Dootz, B
X-ray findings are described, which are typical for injuries due to conventional weapons. It is intended to demonstrate that radiographs can show findings characteristic for weapons. The radiograms have been collected in Vietnam, Croatia, Serbia, Bosnia, Chad, Iran, Afghanistan, USA, Great Britain, France, Israel, Palestine, and Germany. Radiograms of injuries due to hand grenades show their content (globes) and cover fragments. The globes are localized regionally in the victim's body. Survivors of cluster bombs show singular or few globes; having been hit by many globes would have been lethal. Shotguns produce characteristic distributions of the pallets and depth of penetration different from those of hand grenades and cluster bombs; cover fragments are lacking. Gunshot wounds (GSW) can be differentiated in those to low velocity bullets, high velocity projectiles, and projectiles, which disintegrate on impact. The radiogram furnishes the information about a dangerous shock and helps to recognize the weapon. Radiograms of victims of explosion show fragments and injuries due to the blast, information valid for therapy planning and prognosis. The radiogram shows details which can be used in therapy, forensic medicine and in war propaganda - examples could be findings typical for cluster bombs and for dumdum bullets; it shows the cruelty of the employment of weapons against humans and the conflict between the goal of medical care and those of military actions. Radiographs may show, which weapon has been employed; they can be read as war reports.
Koto, Modise Zacharia; Matsevych, Oleh Y; Mosai, Fusi; Balabyeki, Moses; Aldous, Colleen
Laparoscopy is increasingly utilised in the trauma setting. However, its safety and reliability in evaluating and managing retroperitoneal injuries are not known. The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries due to penetrating abdominal trauma (PAT) and to investigate its feasibility, safety and accuracy in haemodynamically stable patients. Over a 4-year period, patients approached laparoscopically with retroperitoneal injuries were analysed. Mechanism, location and severity of injuries were recorded. Surgical procedures, conversion rate and reasons for conversion and outcomes were described. Of the 284 patients with PAT, 56 patients had involvement of retroperitoneum. Stab wounds accounted 62.5% of patients. The mean Injury Severity Score was 7.4 (4-20). Among retroperitoneal injuries, the colon (27%) was the most commonly involved hollow viscera followed by duodenum (5%). The kidney (5%) and the pancreas (4%) were the injured solid organs. The conversion rate was 19.6% and was mainly due to active bleeding (73%). Significantly more patients with gunshot wound were converted to laparotomy (38% vs. 9%). Therapeutic laparoscopy was performed in 36% of patients. There were no recorded missed injuries or mortality. Five (9%) patients developed the Clavien-Dindo Grade 3 complications, three were managed with reoperation, one with drainage/debridement and one with endovascular technique. Laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. However, a high conversion rate indicates difficulties in managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding.
Introduction The extent of wound contamination in gunshot injuries is still a topic of controversial debate. The purpose of the present study is to develop a model that illustrates the contamination of wounds with exogenous particles along the bullet path. Material and methods To simulate bacteria, radio-opaque barium titanate (3-6 μm in diameter) was atomized in a dust chamber. Full metal jacket or soft point bullets caliber .222 (n = 12, v0 = 1096 m/s) were fired through the chamber into a gelatin block directly behind it. After that, the gelatin block underwent multi-slice CT in order to analyze the permanent and temporary wound cavity. Results The permanent cavity caused by both types of projectiles showed deposits of barium titanate distributed over the entire bullet path. Full metal jacket bullets left only few traces of barium titanate in the temporary cavity. In contrast, the soft point bullets disintegrated completely, and barium titanate covered the entire wound cavity. Discussion Deep penetration of potential exogenous bacteria can be simulated easily and reproducibly with barium titanate particles shot into a gelatin block. Additionally, this procedure permits conclusions to be drawn about the distribution of possible contaminants and thus can yield essential findings in terms of necessary therapeutic procedures. PMID:22032229
Xing, Liyu; Culbertson, Eric J.; Wen, Yuan; Robson, Martin C.
Background Obesity increases the risk of laparotomy dehiscence and incisional hernia. The aim of this study was to measure the biological effect of obesity on laparotomy wound healing and the formation of incisional hernias. Methods Normal-weight Sprague–Dawley (SD) and obese Zucker rats were used in an established laparotomy wound healing and incisional ventral hernia model. Mechanical testing was performed on abdominal wall strips collected from laparotomy wounds. Hernia size was measured by digital imaging. Picrosirius staining for collagen isoforms was observed with polarized microscopy. Abdominal wall fibroblasts were cultured to measure collagen matrix remodeling and proliferation. Results Laparotomy wound healing was significantly impaired in obese rats. Mechanical strength was lower than in normal-weight rats. Yield load was reduced in the obese group at all time points. Picrosirius red staining showed increased immature type III collagen content and disorganized type I collagen fibers within laparotomy wounds of obese rats. Wound size was significantly larger in the obese group. Collagen matrix remodeling was impaired with fibroblasts from obese rats, but there was no difference in fibroblast proliferation between the obese and normal-weight groups. Conclusions We observed for the first time that laparotomy wound healing is impaired in obese rats. The recovery of laparotomy wound strength is delayed due to abnormal collagen maturation and remodeling, possibly due to a defect in fibroblast function. Strategies to improve outcomes for laparotomy wound healing in obese patients should include correcting the wound healing defect, possibly with growth factor or cell therapy. PMID:21347822
Matres-Lorenzo, Luis; Bernardé, Antoine; Bernard, Fabrice
To describe the surgical management and long-term outcome of a spinal gunshot injury in a cat. A two-year-old, 4.2 kg castrated European Shorthair male cat was referred for evaluation of bilateral acute hindlimb paralysis with loss of deep pain perception in the right hindlimb associated with a perforating gunshot wound in the left side of the flank. Based on the clinical findings, the injury was localized to the fourth lumbar-first sacral spinal cord segment. The orthogonal spinal radiographs and computed tomography examination showed several metal pellet fragments within the vertebral canal of the sixth lumbar vertebra. A left mini-hemilaminectomy of the sixth lumbar vertebra pedicle combined with a mini dorsal laminectomy over the sixth to seventh lumbar vertebrae disc space were performed. A 2.4 mm 30° arthroscope was then introduced within the spinal canal to improve visibility and help with the fragment extraction. The cat was discharged from the hospital five days after surgery and the owners were encouraged to continue passive and active physiotherapy movements. The cat was ambulatory with a plantigrade stance eight weeks following surgery. At the last follow-up examination (24 months postoperatively), the cat was able to jump on chairs, although intermittent urinary and faecal incontinence, proprioceptive deficits, and plantigrade stance were still present. Decompressive surgery may promote neurological status improvement following spinal gunshot injury.
Olsen, Lisa E; Streeter, Elizabeth M; DeCook, Rhonda R
To describe the signalment, wound characteristics, and treatment of gunshot injuries in cats and dogs in urban and rural environments, and to evaluate the utility of the animal trauma triage (ATT) score as an early predictor of survival to discharge from the hospital. Retrospective case series. 29 dogs and 8 cats. Medical records of cats and dogs evaluated for gunshot wounds from 2003 and 2008 at a private urban referral practice in Cedar Rapids, Iowa, and an urban veterinary teaching hospital in Ames, Iowa, were reviewed. Information collected included signalment, chief reason for evaluation, circumstance of the injury, general physical examination findings, wound characteristics, treatments provided, cost of care, survival to discharge from the hospital (yes vs no), and duration of hospital stay. For each animal, ATT scores were calculated and evaluated as a prognostic tool. 37 animals met study inclusion criteria. Animals with higher ATT scores had a greater likelihood of poor outcome following gunshot injury. Animals with higher ATT scores, classified as low (< 4.5) or high (> 4.5), were found to have a longer duration of stay, classified as zero (0 days), short (1 to 3 days), or long (> 3 days). Young male dogs generally considered working breeds were overrepresented (29/37 [78.4%]). A preference for low-velocity, low-kinetic-energy firearms was identified (19/37 [52%]). The most numerous wounds were those inflicted to the limbs (12/37 [32.4%]), during low-visibility hours or hunting excursions. Calculated ATT scores on admission were higher in animals requiring blood products or surgical procedures and in nonsurvivors. Results of the present study suggested that regional preferences in breed ownership and firearm choice are responsible for variation in gunshot injury characteristics and management in animals sustaining injuries in rural and urban settings in Iowa. In cats and dogs, calculation of an ATT score may provide a useful predictor of the need for
Thali, M J; Kneubuehl, B P; Dirnhofer, R; Zollinger, U
Forensic science uses substitutes to reconstruct injury patterns in order to answer questions regarding the dynamic formation of unusual injuries. Using a case study, an experimental simulation of a finger was designed, for the first time with a combination of hard wood and glycerin soap. With this model as an intermediate target simulation, it was possible not only to demonstrate the "bullet-body (finger) interaction", but also to recreate the wound pattern found in the victim. This case demonstrates that by using ballistic models and body-part substitutes, gunshot cases can be reproduced simply and economically, without coming into conflict with ethical guidelines.
Burningham, M D; Walter, F G; Mechem, C; Haber, J; Ekins, B R
Wound botulism is a rare infectious and toxicologic complication of trauma and i.v. drug abuse. Only 39 cases have been reported in detail in the English literature. This case report describes a patient with wound botulism who presented to four medical facilities before receiving definitive diagnosis and treatment. Although his history and physical examination were consistent with wound botulism, diagnosis and therapy were delayed because this rare disease was not considered initially in the differential diagnosis. Wound botulism should be considered in trauma patients and i.v. drug abusers who present with cranial nerve palsies and descending paresis.
Stefanopoulos, P K; Pinialidis, D E; Hadjigeorgiou, G F; Filippakis, K N
The mechanisms of soft tissue injury by bullets are reviewed, in the belief that the current incidence of firearm injuries in many urban areas necessitates an understanding of wound ballistics on the part of trauma surgeons who may not be familiar with the wounding factors involved. Review of the literature, with technical information obtained from appropriate non-medical texts. Despite numerous publications concerning the treatment of gunshot wounds, relatively few papers contain details on the mechanisms of ballistic trauma, with the main body of evidence derived from previous laboratory and animal studies which have only recently been systematically appraised. These studies have shown that in rifle injuries the main wound tract is surrounded by an area of damaged tissue as a result of the temporary cavitation induced once the bullet becomes destabilized or deformed. On the other hand, the more commonly encountered non-deforming handgun bullets cause damage limited to the bullet's path, mainly as a result of localized crush injury. The bullet's construction and ballistic behavior within tissue determine to what extent the previously overestimated velocity factor may influence wound severity. The damage produced from temporary cavitation depends on the tensile properties of the tissues involved, and in high-energy injuries may lead to progressive muscle tissue necrosis. Therefore, the term "high-energy" should be reserved for those injuries with substantial tissue damage extending beyond the visible wound tract.
Sido, B; Grenacher, L; Friess, H; Büchler, M W
Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.
Ramos, Antonio L. L.; Holm, Sverre; Gudvangen, Sigmund; Otterlei, Ragnvald
Acoustical sniper positioning systems rely on the detection and direction-of-arrival (DOA) estimation of the shockwave and the muzzle blast in order to provide an estimate of a potential snipers location. Field tests have shown that detecting and estimating the DOA of the muzzle blast is a rather difficult task in the presence of background noise sources, e.g., vehicle noise, especially in long range detection and absorbing terrains. In our previous work presented in the 2011 edition of this conference we highlight the importance of improving the SNR of the gunshot signals prior to the detection and recognition stages, aiming at lowering the false alarm and miss-detection rates and, thereby, increasing the reliability of the system. This paper reports on real-time noise cancellation techniques, like Spectral Subtraction and Adaptive Filtering, applied to gunshot signals. Our model assumes the background noise as being short-time stationary and uncorrelated to the impulsive gunshot signals. In practice, relatively long periods without signal occur and can be used to estimate the noise spectrum and its first and second order statistics as required in the spectral subtraction and adaptive filtering techniques, respectively. The results presented in this work are supported with extensive simulations based on real data.
Smith, E Reed; Shapiro, Geoff; Sarani, Babak
Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma. A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury. There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head. A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.
... wounds need care to prevent infection. Stages of Wound Healing Wounds heal in stages. The smaller the wound, ... How lacerations heal References Leong M, Phillips LG. Wound healing. In: Townsend CM, Beauchamp RD, Evers BM, Mattox ...
Matoso, Rodrigo Ivo; Freire, Alexandre Rodrigues; Santos, Leonardo Soriano de Mello; Daruge Junior, Eduardo; Rossi, Ana Claudia; Prado, Felippe Bevilacqua
Firearms can cause fatal wounds, which can be identified by traces on or around the body. However, there are cases where neither the bullet nor gun is found at the crime scene. Ballistic research involving finite element models can reproduce computational biomechanical conditions, without compromising bioethics, as they involve no direct tests on animals or humans. This study aims to compare the morphologies of gunshot entrance holes caused by.40-caliber Smith & Wesson (S&W), .380-caliber, and 9×19-mm Luger bullets. A fully metal-jacketed.40 S&W projectile, a fully metal-jacketed.380 projectile, and a fully metal-jacketed 9×19-mm Luger projectile were computationally fired at the glabellar region of the finite element model from a distance of 10 cm, at perpendicular incidence. The results show different morphologies in the entrance holes produced by the three bullets, using the same skull at the same shot distance. The results and traits of the entrance holes are discussed. Finite element models allow feasible computational ballistic research, which may be useful to forensic experts when comparing and analyzing data related to gunshot wounds in the forehead. PMID:25343337
Ateşalp, A Sabri; Kömürcü, Mahmut; Demiralp, Bahtiyar; Bek, Dogan; Oğuz, Erbil; Yanmiş, Ibrahim
Lower extremity injuries secondary to close-range, low-velocity gunshot wounds are frequently seen in both civilian and military populations. A close-range, low-velocity injury produces high energy and often results in comminuted and complicated fractures with significant morbidity. In this study, four femoral, four tibial, and three combined tibia and fibular comminuted diaphyseal fractures secondary to close-range, low-velocity gunshot wounds in 11 military personnel were treated with debridement followed by compression-distraction lengthening using a circular external fixator frame. Fracture union was obtained in all without significant major complications. Fracture consolidation occurred at a mean of 3.5 months. At follow-up of 46.8 months, there were no delayed unions, nonunions, or malunions. Minor complications included four pin-tract infections and knee flexion limitation in two femur fractures. Osteomyelitis and deep soft tissue infection were not observed. This technique provided an alternative to casting, open reduction internal fixation, or intermedullary fixation with an acceptable complication rate.
Peled, Micha; Leiser, Yoav; Emodi, Omri; Krausz, Amir
Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time. PMID:23449809
Parks, Susan E; Hotchkin, Cara F; Cortopassi, Kathryn A; Clark, Christopher W
North Atlantic right whales (Eubalaena glacialis) produce a loud, broadband signal referred to as the gunshot sound. These distinctive sounds may be suitable for passive acoustic monitoring and detection of right whales; however, little is known about the prevalence of these sounds in important right whale habitats, such as the Bay of Fundy. This study investigates the timing and distribution of gunshot sound production on the summer feeding grounds using an array of five marine acoustic recording units deployed in the Bay of Fundy, Canada in mid-summer 2004 and 2005. Gunshot sounds were common, detected on 37 of 38 recording days. Stereotyped gunshot bouts averaged 1.5 h, with some bouts exceeding 7 h in duration with up to seven individuals producing gunshots at any one time. Bouts were more commonly detected in the late afternoon and evening than during the morning hours. Locations of gunshots in bouts indicated that whales producing the sounds were either stationary or showed directional travel, suggesting gunshots have different communication functions depending on behavioral context. These results indicate that gunshots are a common right whale sound produced during the summer months and are an important component in the acoustic communication system of this endangered species.
Matthews, Marc R.; Quan, Asia N.; Weir, Alexandra S.; Foster, Kevin N.; Caruso, Daniel M.
Introduction: Leaving the abdominal cavity open is a well-described and frequently utilized technique in the treatment of severe intra-abdominal sepsis. Irrigation through a negative pressure wound therapy device is a technique employed to assist in the closure of wounds as well as the reduction of bacterial contamination. Furthermore, hypochlorous acid has been found to be safe and effective in microorganismal elimination from extremity wounds. There is no literature regarding the infusion of hypochlorous solution into the abdominal cavity for intra-abdominal sepsis or mucopurulent abscesses or biofilm. Objectives: A 47-year-old man with granulomatosis polyangiitis was started on weekly rituximab. After 4 infusions, skin sloughing, ultimately diagnosed as toxic epidermal necrolysis, developed. During the hospital course, he developed sepsis and bowel perforation necessitating an exploratory laparotomy. The abdomen was left open with a temporary abdominal closure using the Abthera open abdomen negative wound therapy device; however, the abdomen remained infected with visually diffuse, thickening mucopurulence despite multiple washouts. Therefore, a VAC Vera-Flo irrigation device was combined with the Abthera open abdomen negative wound therapy device and cyclical irrigation of hypochlorous acid. After 72 hours, the purulence visually was improved and no adverse events were recorded with the placement of intra-abdominal hypochlorous acid. Conclusions: The combination of two medical devices for the intra-abdominal instillation of irrigation is considered “off-label use” from the manufacturer's recommendations. In addition, the repeated instillation of hypochlorous acid solution has not been described but was noted to have visually decreased the contaminated effluent within the intra-abdominal fluid. PMID:29527250
Sabbatani, Sergio; Fiorino, Sirio
The First World War was a huge tragedy for mankind, but, paradoxically, it represented a source of significant progress in a broad series of human activities, including medicine, since it forced physicians to improve their knowledge in the treatment of a large number of wounded soldiers. The use of heavy artillery and machine guns, as well as chemical warfare, caused very serious and life-threatening lesions and wounds. The most frequent causes of death were not mainly related to gunshot wounds, but rather to fractures, tetanus and septic complications of infectious diseases. In the first part of this article, we describe the surgical procedures and medical therapies carried out by Italian physicians during the First World War, with the aim of treating wounded soldiers in this pre-antibiotic era. Antibacterial solutions, such as those of Dakin-Carrel and sodium hypochlorite and boric acid, the tincture of iodine as well as the surgical and dressing approaches and techniques used to remove pus from wounds, such as ignipuncture and thermocautery or lamellar drainage are reported in detail. In the second part of the paper, the organization of the Italian military hospitals network, the systems and tools useful to transport wounded soldiers both in the front lines and in the rear is amply discussed. In addition, the number of soldiers enrolling, and those dying, wounded or missing during the Great War on the Italian front is estimated.
De Waele, Jan J
Abdominal infections are an important challenge for the intensive care physician. In an era of increasing antimicrobial resistance, selecting the appropriate regimen is important and, with new drugs coming to the market, correct use is important more than ever before and abdominal infections are an excellent target for antimicrobial stewardship programs. Biomarkers may be helpful, but their exact role in managing abdominal infections remains incompletely understood. Source control also remains an ongoing conundrum, and evidence is increasing that its importance supersedes the impact of antibiotic therapy. New strategies such as open abdomen management may offer added benefit in severely ill patients, but more data are needed to identify its exact role. The role of fungi and the need for antifungal coverage, on the other hand, have been investigated extensively in recent years, but at this point, it remains unclear who requires empirical as well as directed therapy.
Jean, Yuel-Kai; Potnuru, Paul; Diez, Christian
We present an approach to airway management in a patient with machete injuries culminating in near-complete cricotracheal transection, in addition to a gunshot wound to the neck. Initial airway was established by direct intubation through the cricotracheal wound. Once the airway was secured, a bronchoscopy-guided orotracheal intubation was performed with simultaneous retraction of the cricotracheal airway to optimize the surgical field. This case offers insight into a rarely performed approach to airway management. Furthermore, our case report demonstrates that, in select airway injuries, performing through-the-wound intubation engenders a multitude of benefits.
MacCrehan, William A; Layman, Malinda J; Secl, Janelle D
A protocol is presented for the collection and analysis of gunshot residues (GSR) from hair. A fine-toothed comb is used for collection of the residues. A small zip-closure bag serves as a container for both sample storage and extraction of the characteristic organic powder additives. The success of this residue recovery approach was tested on simulated shooters and victims using mannequin-supported human wig hair as well as on human shooters. Residues were collected from four weapons: a revolver and semi-automatic pistol, rifle and shotgun. One characteristic additive, nitroglycerin, was detected by capillary electrophoresis (CE) in the majority of the collection experiments.
Krywanczyk, Alison; Shapiro, Steven
The distinction between self-inflicted blade wounds and blade wounds inflicted by another can be difficult in situations where there is little available history or context. We reviewed homicides and suicides in the past 10 years at the Vermont Office of the Chief Medical Examiner to define the characteristics of homicidal and suicidal blade wounds. All homicides and suicides involving blade wounds, not just those in which blade wounds were the cause of death, were included. Information regarding victim demographics, location and type of injuries, toxicology, and evidence of suicidality was gathered. Blade wounds were the cause of death in 85.7% of homicides but only in 36% of suicides. Hanging and gunshot wounds were the cause of death in 28% and 24% of suicides, respectively. Multiple stab wounds were found in 10% of homicides and in 0% of suicides, whereas multiple incised wounds were found in 60% of suicides and only 10% of homicides. However, several unusual instances of suicide were found, including suicides with clothing damage or bone or cartilage injury from blade wounds. No characteristics of blade wounds were definitive for homicide or suicide. History and circumstances of the scene are thus crucial in determining the manner of death.
Kieser, Jules A; Tahere, Joy; Agnew, Caitlin; Kieser, David C; Duncan, Warwick; Swain, Michael V; Reeves, Matthew T
Understanding how bone behaves when subjected to ballistic impact is of critical importance for forensic questions, such as the reconstruction of shooting events. Yet the literature addressing microscopic anatomical features of gunshot wounds to different types of bone is sparse. Moreover, a biomechanical framework for describing how the complex architecture of bone affects its failure during such impact is lacking. The aim of this study was to examine the morphological features associated with experimental gunshot wounds in slaughtered pig ribs. We shot the 4th rib of 12 adult pigs with .22 mm subsonic bullets at close range (5 cm) and examined resultant wounds under the light microscope, scanning electron microscope SEM and micro tomograph μCT. In all cases there was a narrow shot channel followed by spall region, with evidence of plastic deformation with burnishing of the surface bone in the former, and brittle fracture around and through individual Haversian systems in the latter. In all but one case, the entrance wounds were characterized by superficially fractured cortical bone in the form of a well-defined collar, while the exit wounds showed delamination of the periosteum. Inorganic residue was evident in all cases, with electron energy dispersive spectroscopy EDS confirming the presence of carbon, phosphate, lead and calcium. This material appeared to be especially concentrated within the fractured bony collar at the entrance. We conclude that gunshot wounds in flat bones may be morphologically divided into a thin burnished zone at the entry site, and a fracture zone at the exit.
... other symptoms do you have at the same time? For example, do you have abdominal pain ? You may have the following tests: Barium studies of the stomach and intestines (such as an upper GI series ) Blood tests Colonoscopy Gastroscopy Peritoneal lavage Stool studies ...
Jiménez Gómez, M; Betancor Rivera, N; Lima Sánchez, J; Hernández Hernández, J R
Abdominal traumatic evisceration as a result of high energy trauma is uncommon. Once repaired the possible internal damage, an abdominal wall defect of high complexity may exist, whose reconstruction represents a surgical challenge. Politraumatized male with important abdominal muculocutaneous avulsion and evisceration. After initial repair, the patient developed a big eventration in which we use a porcine dermis-derived mesh (Permacol TM ), a safe and effective alternative in abdominal wall repair, thanks to its seamless integration with other tissues, even when exposed. Negative pressure therapy has been used for the management of wound complications after surgical implantation of PermacolTM mesh. We describe our experience with the use of PermacolTM mesh and negative pressure therapy to aid the wound closure after skin necrosis and exposed mesh.
Liu, Haijun; Currano, Luke; Gee, Danny; Yang, Benjamin; Yu, Miao
The supersensitive ears of the parasitoid fly Ormia ochracea have inspired researchers to develop bio-inspired directional microphone for sound localization. Although the fly ear is optimized for localizing the narrow-band calling song of crickets at 5 kHz, experiments and simulation have shown that it can amplify directional cues for a wide frequency range. In this article, a theoretical investigation is presented to study the use of fly-ear inspired directional microphones for gunshot localization. Using an equivalent 2-DOF model of the fly ear, the time responses of the fly ear structure to a typical shock wave are obtained and the associated time delay is estimated by using cross-correlation. Both near-field and far-field scenarios are considered. The simulation shows that the fly ear can greatly amplify the time delay by ~20 times, which indicates that with an interaural distance of only 1.2 mm the fly ear is able to generate a time delay comparable to that obtained by a conventional microphone pair with a separation as large as 24 mm. Since the parameters of the fly ear structure can also be tuned for muzzle blast and other impulse stimulus, fly-ear inspired acoustic sensors offers great potential for developing portable gunshot localization systems.
Bakir, Abdurrahman; Temiz, Cüneyt; Umur, Sukru; Aydin, Varol; Torun, Fuat
Head injuries due to high-velocity missiles and shrapnel as a result of military conflicts have become a very important cause of death or severe neurological deficits. Military-type missiles have high velocities and transfer higher amounts of energy to neural tissue, compared to civil-type missiles. This physical phenomenon also causes greater neural tissue destruction. Shrapnel particles derive from blasts and cause less severe injury because of the irregular particle shape and low energy transmission. This study analyzed 135 patients with head trauma, 80 patients (59%) injured by missiles and 55 patients (41%) by shrapnel. Glasgow Coma Scale (GCS) scores at admission were 3 to 7 in 69 patients, 8 to 10 in 29 patients, and 11 to 15 in 37 patients. The most common anatomical localizations were the right frontoparietal region in 42 patients and the left frontoparietal region in 40 patients. One hundred patients (74%) were operated on immediately and 35 patients (26%) were treated conservatively in the intensive care unit. Ten of the 135 patients died (7.4%), seven from missile injury and three from shrapnel injury. In this study, we found that high mortality was associated with low GCS score at admission, presence of multilobar or skull base injuries, and involvement of ventricles. Early and aggressive surgical intervention decreased the mortality.
Gokkus, Kemal; Sagtas, Ergin; Suslu, Feride Ekimler; Aydin, Ahmet Turan
This report concerns an unusual cause of sciatica. The case presented is of a young man with myositis ossificans that resulted in sciatica and was treated with en bloc excision and low-dose radiotherapy and indomethacine. The aim of this study was to explain the different diagnostic properties of myositis ossificans around the hip and non-classic causes of sciatica.
Su, Charles A; Nguyen, Mai P; O'Donnell, Jeffrey A; Vallier, Heather A
The purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW. A retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations. Deep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p < 0.05), type IIIA (19.5%, p < 0.05), and type IIIB fractures (47%, p < 0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p = 0.2). Nonunions were more common after open fractures from blunt trauma (11%, p < 0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p < 0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p = 0.19). While GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures. Copyright © 2018. Published by Elsevier Ltd.
Vogels, J; Pommier, N; Cursolle, J-C; Belin, C; Tournier, C; Durandeau, A
Open fractures of the shoulder are extremely rare, and their treatment is a major challenge for surgeons. Only cases encountered in military settings have been reported thus far. Such fractures are often the result of ballistic trauma, which causes extensive damage to both bony and soft tissues. Since these injuries are associated with a high risk of infection and the presence of comminuted fractures, external fixation is necessary for repair. Use of external fixators and revascularization techniques has reduced the number of cases requiring shoulder amputation or disarticulation. Injury to the proximal extremity of the humerus, acromion, and clavicle further complicates the treatment. No published studies have described the assembly of external fixators for fractures in the scapular region with significant bone loss. In addition, no cases have been described in civilian settings. However, with an increase in urban violence and the traffic of illegal arms, civilian surgeons are now encountering an increasing number of patients with these injuries. In this report, we not only present a rare case of floating shoulder injury in a civilian setting but also provide an overview of the existing treatment strategies for this type of trauma, with special focus on the use of external fixators in elective shoulder arthrodesis and on military cases. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Ozertskovskiĭ, L B; Tiurin, M V; Denisov, A V
A series of experimental studies was conducted with the object of elucidating the mechanisms of the bullet after-penetration effect produced by a handgun shot into the armoured vest with special reference to the changes developing in the space behind the barrier. The application of the pulsed radiographic technique revealed a transient cavity the presence of which accounts for the injuries to soft tissues, bones, and internal organs in the projection of the bullet impact without damage to the armour plates.
Kaufman, H H; Levy, M L; Stone, J L; Masri, L S; Lichtor, T; Lavine, S D; Fitzgerald, L F; Apuzzo, M L
Even this information is only partial. To study fully the effects of treatment would require optimal care at all points from time of injury, including rapid prehospital resuscitation, rapid transport to an optimally equipped and staffed hospital, immediate evaluation and treatment of the initial injury and all complications, rapid and comprehensive rehabilitation, and supportive and flexible home and work settings for the patient on discharge. Patients would need to be stratified for premorbid characteristics, including intelligence, personal traits, and training. Prolonged follow-up, possibly for several years, would be required to determine true outcome. No current study contains sufficient numbers of patients treated optimally and studied for prolonged periods, but this should be done. One way of looking at such patients is to decide that many should be treated to salvage a few. The other way of looking at them is that so many must receive care, at great emotional and economic cost to themselves and others, that such treatment is inappropriate for any of them. Treating all such patients would be a major undertaking. If most of these patients were treated vigorously, a great proportion of them would still die but probably not for a number of days. During this period, their families would be under extreme stress. Once stabilized and receiving ongoing care, some patients would enter a permanent vegetative state and survive for prolonged periods until their prognosis was clear and care was withdrawn, again causing family stress as well as high cost. Some would likely survive although impaired. The charges and real costs of care for all these patients would be tremendous. The question therefore arises as to how to decide what to do about caring for a large group of patients whose maximal care would be costly in emotional and financial terms, particularly at a time when it is recognized that resources for medical care are going to be limited. When discussing such patients as a group with a view toward developing practice guidelines, many considerations must be brought to bear. One consideration is the certainty of the prognosis in both a quantitative and a qualitative sense in an individual case. It is not clear that one can be certain in patients except when there are overwhelmingly unfavorable features. As has been noted, even patients who have been shot through the geographic center of the brain and are posturing can make excellent recoveries. This would push toward aggressive treatment for many patients. Decision making must therefore be considered in terms of bioethics. The major principle-based systems of bioethics are deontologic, arising from accepted principles, and utilitarian, arising from effect on outcome. A virtue-based ethic for physicians arising from "the caring bond and the public trust" is being revived as a balance to analytical ethics. A similar orientation from the point of view of patients is communitarian ethics, that is asking for only what is reasonable and not so much as might harm others. Some of the issues to be considered include the sanctity of life while taking into account the criteria for life--vegetative function versus some level of mental function. One must also review each decision from the viewpoints of all the parties involved--patients, family and friends, physicians, and society--in the context of a heterogeneous society in which individual rights and tolerance enforced by law are primary features. In the patients' terms, there is a desire and right to medical care to maintain a healthy productive life. Even if impaired to some extent, patients may still have an interest in living. Balancing benefits and burdens of life is a complex problem. There is also the right, based on patients' values, to refuse care if there is the wish not to take a chance of having a significantly compromised existence. Such declaration before injury should be honored...
Pollock, A. V.; Evans, M.; Smith, G. M.
A total of 624 consecutive eligible patients undergoing abdominal operations received a single preoperative dose of amoxycillin/clavulanic acid (1.2 g Augmentin) for the prophylaxis of surgical wound infection. They were randomised to have the antibiotic injected intravenously at induction of anaesthesia (n = 328) or infiltrated subcutaneously along the line of the proposed incision (n = 296). The incidence of wound infections was considerably lower in the group given the antibiotic into the abdominal wall (8.4% compared with 15.9%--chi 2 = 7.90, P = 0.005). No significant differences were found in the incidence of other major or minor infective or non-infective postoperative complications between the groups. It is concluded that preincisional intraparietal injection is more effective than intravenous injection of Augmentin for the prophylaxis of surgical wound infection. PMID:2523210
Bozeman, Matthew C; Ross, Charles B
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.
Bozeman, Matthew C.; Ross, Charles B.
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events. PMID:22454763
Ballistics involves the study of the scientific properties of projectiles, their behavior and their terminal effects on biological tissues and other materials. Wound ballistics deals with the analysis of injuries caused by projectiles and the behavior of projectiles within human or other biological tissues. The nineteenth century witnessed the development of both of these areas with Kocher's hydrodynamic theory and the understanding of the significance of bullet deformation in causing tissue injury. The degree of traumatic disruption of tissues and organs was also related to direct energy transfer from projectiles. While subsequent research has concentrated on elucidating further mechanisms of injury, the exact cause of remote tissue damage from high energy projectiles is still the subject of ongoing research. Much of the contemporary literature regarding wound ballistics concentrates on the forensic aspects and their application for legal purposes, in particular the investigation of shooting scenes. There have been many advances in this area, particularly in relation to the identification of various types of gunshot wounds and how their appearance can be used to establish if a shooting was accidental, deliberate (homicidal) or self inflicted (suicidal).
Chopra, Teena; Marchaim, Dror; Awali, Reda A; Levine, Miriam; Sathyaprakash, Smitha; Chalana, Indu K; Ahmed, Farah; Martin, Emily T; Sieggreen, Mary; Sobel, Jack D; Kaye, Keith S
Management of pressure ulcers (PrUs) in patients with gunshot-spinal cord injuries (SCIs) presents unique medical and economic challenges for practitioners. A retrospective chart review was conducted at 3 acute care hospitals in metropolitan Detroit for patients admitted with PrUs due to gunshot-SCIs between January 2004 and December 2008. Multivariate analysis using logistic regression was conducted to choose for the independent predictors of infected PrUs. Mean adjusted in-hospital costs per patient and per hospitalization were calculated and compared between infected and noninfected PrUs. The study cohort included 201 gunshot-SCI patients with PrUs contributing to 395 admissions, including readmissions, between 2004 and 2008. Seventy-six patients (38%) had infected PrUs at time of the index admission. Independent predictors of infected PrUs on index admission included Charlson Comorbidity Index ≥2 (odds ratio, 2.18, P = .026) and stage III/IV PrU (odds ratio, 4.82; P <.0001). During the study period, the cumulative median duration of hospitalization per patient was 12 days (interquartile range, 6-24 days), resulting in a mean adjusted cost of $19,969 ± $6639 per patient. The mean adjusted cost per hospitalization for patients with infected PrUs was significantly higher than that for patients with noninfected PrUs ($16,735 ± $8310 vs $12,356 ± $7007; P <.001). A multidisciplinary approach including home-based rehabilitation programs and SCI wound clinics might help prevent PrUs and their complications and reduce associated costs. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Suicidal gunshot wounds that are caused by ammunition fired from a 9-mm Luger pistol, with direct contact between the gun muzzle and the victim's head, present a serious injury pattern even with full metal jacket bullets. Wound ballistic experiments were performed to clarify whether muzzle gases from the firearm have an additional wounding potential. Fifteen head models were prepared as follows: an acryl sphere measuring 14 cm in diameter was completely covered with a layer of silicon that was 3 mm thick. These spheres were filled with 10% gelatine. At 4°C, these models were fired at with a 9-mm Luger pistol, loaded with Quick Defense 1 expanding bullets. Five shots were fired with direct muzzle contact, one shot was fired from a distance of 10 cm, four shots were fired from a distance of 2 m, and five shots were fired from a distance of 4 m. Each projectile penetrated the model; all but one projectile deformed regularly. Each acryl sphere shattered into comminuted pieces but was held together by the silicon cover. The gelatine filling was then cut into slices 1 cm thick, and each slice was optically scanned. An evaluation was performed following both Fackler's Wound Profile method and the polygon procedure method. The pattern of gelatine disruption did not differ in shots from intermediate ranges, but the amount of gelatine destruction was always more extended in the case of muzzle contact shots. Depending on the section of the bullet path, crack lengths were 31% to 133% longer in contact shots. The first centimetre and the second half of the bullet path showed the greatest increase. The experimental findings prove the wounding capacity of muzzle gases.
Dalgic, Ali; Okay, Onder; Nacar, Osman; Daglioglu, Ergun; Pasaoglu, Lale; Belen, Deniz
The vertebral artery (VA) is well protected through its course at the cervical transverse foramina and penetrating injuries of VA are mostly caused by gun shot wounds. The mechanism of injury in these wounds is described as the kinetic energy transferred by the bullet, which always depends on its mass and speed. Thus, the size of the pellet is the most important factor for the tissue damage, shock waves and direct injury. Civilian gun shot wounds are generally caused by low velocity firearms, In this report, we described two cases with cervical gunshot wound characterized with transverse foramina damage and VA insult. The first patient was assaulted by bullet that resulted in vertebral artery occlusion, whereas a smaller pellet was found in the second one and arterial flow was not influenced on the site of the damaged transverse foramina. Successful management of these injuries should include careful analysis of the bullet characteristics that is directly related to the intensity of damage.
Blakey, Lauren S; Sharples, George P; Chana, Kal; Birkett, Jason W
A review of the literature concerning the fate and behavior of gunshot residue (GSR) is presented. A number of concomitant parameters including firearm and ammunition type, plume and GSR material characteristics, travel distances, chemical composition and GSR morphology are critically discussed in relation to their effects on the distribution and deposition, transfer and persistence processes of GSR. The underlying mechanisms associated with such processes are also considered. Knowledge of these processes on GSR materials could provide valuable information concerning scene preservation and subsequent forensic sampling. The number of GSR particles deposited can vary significantly with each firearm discharge, highlighting the potential to produce distinctive data in each individual case. With the continual development and compositional changes of new ammunition types, further evaluation of the effect these processes may have on GSR evidence and their possible influence on the interpretation of the analytical results should be given due consideration. © 2017 American Academy of Forensic Sciences.
Leonov, S V
The objective of the present work was to study the mechanisms of formation of the gunshot fracture of the flat bones with special reference to the translational and rotational motion of the projectile. A total of 120 real and experimental injuries of this type were available for the investigation with the use of simulation by the finite-elemental analysis. A set of morphological features has been identified that make it possible to determine the direction of rotation of the gunshot projectile.
Rodacy, Philip J.; Walker, Pamela K.
A field test kit for gunshot residue comprises a container having at least compartments separated by a barrier. A surface is tested by wiping it with a swab and placing the swab in a first compartment. The barrier is then breached, permitting reagent in the second compartment to flow onto the swab. The first compartment is transparent, and a color change will be observed if the reagent reacts with gunshot residue.
Weber, I T; Melo, A J G; Lucena, M A M; Consoli, E F; Rodrigues, M O; de Sá, G F; Maldaner, A O; Talhavini, M; Alves, S
Chemical evaluation of gunshot residues (GSR) produced by non-toxic lead-free ammunition (NTA) has been a challenge to forensic analyses. Our group developed some luminescent markers specific to the detection of GSR. Here, we evaluated the performance of selected markers in experiments that mimic forensic context and/or routines in which luminescent characteristics would be very useful. We evaluated the influence of markers' addition on the bullet's speed, the rate of shot failure (i.e., when the cartridge case is not fully ejected and/or a new ammunition is not automatically replaced in the gun chamber) as a function of marker percentage, the possibility of collecting luminescent gunshot residue (LGSR) in unconventional locations (e.g. the shooters' nostrils), the LGSR lifetime after hand washing, the transfer of LGSR to objects handled by the shooter, and the dispersion of LGSR at the crime scene and on simulated victims. It was observed that high amounts of marker (10 wt%) cause high rates of failure on pistols, as well as a substantial decrease in bullet speed. However, the use of 2 wt% of marker minimizes these effects and allows LGSR detection, collection and analysis. Moreover, in all conditions tested, markers showed high performance and provided important information for forensic analyses. For instance, the LGSR particles were found on the floor, ranging from 0 to 9.4 m away from the shooter, on the door panel and seats after a car shooting experiment, and were found easily on a pig leg used to simulate a victim. When a selective tagging was done, it was possible to obtain positive or negative correlation between the victim and shooter. Additionally LGSR possesses a fairly long lifetime (9 h) and good resistance to hand washing (up to 16 washes). Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Kozachenko, I N
The classification of the injuries inflicted to the human body by gunshots from the pneumatic weapons remains to be developed. The objective of the present work was to elaborate the classification of the injuries caused by gunshots from the pneumatic weapons based on the analysis of 98 expert and acts of forensic medical expertises (surveys) of living subjects (n=76) and corpses (n=22) affected by gunshots from the pneumatic weapons. These materials were collected from the bureaus of forensic medical expertise in different regions of the Ukraine during the period from 2006 till 2015. In addition, scientific publications concerned with the problem of interest were used along with the relevant explanatory and terminological dictionaries. The terminology and the conceptual framework proposed by the author in the earlier papers provided a basis for the development of the first standard classification of the injuries inflicted to the human body by gunshots from the pneumatic weapons categorized into 15 groups. It is believed that this classification will lay the foundation for the common approach of forensic medical experts to the examination and analysis of the data on the gunshots from the pneumatic weapons used to be found on the bodies of living subjects and the corpses. Moreover, it may be useful for the clinicians in their diagnostic and therapeutic practices and for the legal practitioners engaged in the quality assessment of the results of forensic medical expertises. It is recommended to present information about the gunshots from the pneumatic weapons in the accounting documents in a separate line.
Nuutila, Kristo; Singh, Mansher; Kruse, Carla; Philip, Justin; Caterson, Edward J; Eriksson, Elof
Standardized and reproducible animal models are crucial in medical research. Rodents are commonly used in wound healing studies since, they are easily available, affordable and simple to handle and house. However, the most significant limitation of rodent models is that the wounds heal by contraction while in humans the primary mechanisms of healing are reepithelialization and granulation tissue formation. The robust contraction results in faster wound closure that complicates the reproducibility of rodent studies in clinical trials. We have developed a titanium wound chamber for rodent wound healing research. The chamber is engineered from two pieces of titanium and is placed transcutaneously on the dorsum of a rodent. The chamber inhibits wound contraction and provides a means for controlled monitoring and sampling of the wound environment in vivo with minimal foreign body reaction. This technical report introduces two modalities utilizing the titanium chambers in rats: (1) Wound in a skin island model and, (2) Wound without skin model. Here, we demonstrate in rats how the "wound in a skin island model" slows down wound contraction and how the "wound without skin" model completely prevents the closure. The titanium wound chamber provides a reproducible standardized models for wound healing research in rodents. © 2016 by the Wound Healing Society.
Fackler, M L; Malinowski, J A; Hoxie, S W; Jason, A
The limited disruption produced in tissue simulant by the rifle and bullets used in the Stockton, California, schoolyard shooting is entirely consistent with the autopsy reports on the five children who died of their wounds. It is also entirely consistent with well-documented battlefield studies and with previous tissue-simulant studies from many laboratories. It is inconsistent with many exaggerated accounts of assault-rifle wounding effects described by the media in the aftermath of this incident. This information should be documented for the historical record. However, the critical reason for correcting the misconceptions produced by media reaction to this incident is to prevent inappropriate gunshot-wound treatment.
Amadasi, Alberto; Borgonovo, Simone; Brandone, Alberto; Di Giancamillo, Mauro; Cattaneo, Cristina
The radiological search for GSR is crucial in burnt material although it has been rarely tested. In this study, thirty-one bovine ribs were shot at near-contact range and burnt to calcination in an oven simulating a real combustion. Computed tomography (CT) and magnetic resonance (MR) were performed before and after carbonization and compared with former analyses with DR (digital radiography); thus comparing the assistance, the radiological methods can provide in the search for GSR in fresh and burnt bone. DR demonstrated the greatest ability in the detection of metallic residues, CT showed lower abilities, while MR showed a high sensitivity only in soft tissues. Thus, DR can be considered as the most sensitive method in the detection of GSR in charred bones, whereas CT and MR demonstrated much less reliability. Nonetheless, the MR ameliorates the analysis of gunshot wounds in other types of remains with large quantities of soft tissues. © 2013 American Academy of Forensic Sciences.
Williams, Andrew S; Bowes, Matthew J
Contact-range gunshot wounds commonly demonstrate deposition of black soot in and around the wound. Deposition of other visible pigments originating from the firearm has not been specifically described. In the current case, an adult male was found dead adjacent to a shotgun fixed in a vice grip with a modified, shortened barrel. A handheld, powered, metal grinding wheel was nearby. Autopsy revealed an intraoral gunshot wound, including soot deposition in and around the mouth and within the wound track. In addition, there was a peculiar, gray, lustrous film on the lips, gingiva, and anterior teeth. The material was concentrated around the most severe areas of injury in the anterior mouth and easily rubbed off with a cotton swab. It was not visualized in the rest of the mouth and not present in the larynx, or the esophagus. Overall, our opinion is that this unique, gray, lustrous film represents deposition of fine metallic dust that accumulated in the barrel of the shotgun during its modification with the grinding wheel. This type of unique pigment deposition should be recognized by forensic pathologists as possibly being related to the discharge of a firearm with a recently modified barrel or other cause for fine metallic dust accumulation within the barrel. Depending on the circumstances of the case, collection of samples of such metal dust deposits could be indicated for subsequent analysis.
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Minutolo, Mario; Blandino, Giovanna; Arena, Manuel; Licciardello, Alessio; Di Stefano, Biagio; Lanteri, Raffaele; Puleo, Stefano; Licata, Antonio; Minutolo, Vincenzo
Despite improvements in antibiotic prophylaxis, surgical site infections represent the most common postoperative complication with important clinical consequences for patients. The hypothesis that a bacterial analysis of the surgical wound in the operating room could predict the likelihood of developing a clinical infection, and might allow a tailored and preemptive approach, aimed to reduce the consequences of an infection, seems appealing. We would like to present a prospective study on the predictive value of the bacterial analysis of laparotomy wounds. Seventy eight prospective patients undergoing surgery were included in the study. To evaluate the risk factors associated with increased rate of wound infection, we performed a bacterial analysis of the wound. 48 patients out of 78 (61%) had positive cultures. 23 patients out of 32 patients (72%) who didn't receive antibiotic prophylaxis were positive to the wound culture whereas 25 patients out of 46 patients (54%) grew positive cultures in the group of patients that received antibiotic prophylaxis. None of the 30 patients with negative cultures developed clinical infection. Only 6 patients out of 48 patients who had positive cultures (12.5%) developed wound infection. Clinical infection occurred in 5 patients who had gram-negative contamination of the wound. No clinical infection occurred in patients who had gram-positive contamination. Wound cultures and their positivity are predictive tools to identify the patients that are at risk to develop wound infection. The positive predictive value of the bacterial analysis of the wound was 12.5%. Abdominal surgery, Bacterial analysis, Wound infection.
Johnson, Donald J; Raymond, David E; Chen, Cynthia; Quon, Matthew; Lis, Julian; Choi, Mo Re; Lopez, Christopher; Han, Aileen; de Leon, Ray D; Bir, Cynthia
Previous research by the authors on an animal model showed that bloodstains can contain additional information about their somatic origin in the form of wound cells. Bloodstains produced by a gunshot wound to the head were distinguished from bloodstains produced by a gunshot wound to the chest by testing the stains for a brain microRNA marker. In this study, the effectiveness of the technique was examined on blood drops shed externally from a stab wound to the liver of rat carcasses. Specifically, investigations were conducted on the liver microRNA marker, rno-mir-122-3p, with the QIAGEN miScript System, and PCR analysis. Between the two stabbing methods used, 67% of the scalpel blades and 57% of the blood drops tested positive for rno-mir-122-3p; however, other samples tested negative giving inconclusive results as to the wound-of-origin. The amount of the liver cells in the bloodstains appeared to be related to the extent of trauma. © 2017 American Academy of Forensic Sciences.
Melo, Lis G A; Martiny, Andrea; Pinto, André L
Gunshot residues (GSR) from a total of nine different caliber ammunitions produced in Brazil were analyzed and characterized by transmission (TEM) and scanning electron microscopy (SEM). GSR particles are composed of spherical particles of several micrometers of diameter containing distinct amounts of lead, barium and antimony, along with other organic and inorganic elements arising from the primer, gunpowder, the gun and the bullet itself. This study was carried out to obtain additional information on the properties of GSR nanoparticles originated from different types of regular ammunition produced in Brazil by CBC. Besides the SEM, we have used a TEM, exploring its high magnification capability and ability to explore internal structure and chemical composition of submicron particles. We observed that CBC ammunition generated smaller particles than usually reported for other ammunitions and that the three component particles are not a majority. TEM analysis revealed that GSR are partially composed of sub-micron particles as well. The electron diffraction pattern from these particles confirmed them to be mainly composed of lead oxides crystalline nanoparticles that may be agglomerated into larger particles. Energy dispersive X-ray spectroscopy revealed that most of them were composed of two elements, especially PbSb. Ba was not a common element found in the nanoparticles. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Grima, Matthew; Butler, Mark; Hanson, Robert; Mohameden, Ahmed
In light of past research being targeted to find specific particles which may be similar to gunshot residue (GSR), this project was formulated to detect any possible particulate by random particle fallout onto substrates at firework displays and to assess the impact this may have on GSR evidence. Firework residue was collected at a display site, from amongst spectators as well as from the author's hair 90min after the display. SEM-EDX analysis has detected such particulate in all three scenarios, with the firework particle population at large providing a solid ground for discrimination from GSR. Wind dispersal was found to decrease the particle population and subsequently, the latter's discriminatory power. Some particles, if treated individually were found to be indistinguishable from GSR. Findings also include residues which may mimic strontium based GSR as well as GSR which may be mixed with that from previous firings. The continuous changes made to primer and propellant compositions by manufacturers also call for greater consideration when classifying particles as originating from pyrotechnic devices. Furthermore, authorities such as police forces should be made more aware about the incidence of such particle transfer in firework related periods. Copyright © 2011 Forensic Science Society. Published by Elsevier Ireland Ltd. All rights reserved.
Reed, G E; McGuire, P J; Boehm, A
The results of gunshot residue (GSR) tests in 112 suicide cases investigated by the U.S. Army Criminal Investigation Command over a ten-year period are described. Only suicide cases in which there was certainty that the victim fired a weapon were examined in an effort to reduce ambiguous results. Previous case work research by Rudzitis indicated that positive GSR test results were encountered in suicides 62% of the time using various combinations of neutron activation analysis (NAA) and atomic absorption spectrophotometry (AAS). Threshold values of 0.2-micrograms antimony and 0.3-micrograms barium (0.2-micrograms antimony and 0.5-micrograms barium after 1985) used by the U.S. Army Criminal Investigation Laboratory resulted in positive GSR results in suicide cases 38% of the time. The effects of time, location of body, handling of the body, weapon type, caliber, and condition of the hands on GSR results are examined. Case studies involving suicides by unit armorers are discussed.
Arul, G Suren; Sonka, B J; Lundy, J B; Rickard, R F; Jeffery, S L A
The paradigm of Damage Control Surgery (DCS) has radically improved the management of abdominal trauma, but less well described are the options for managing the abdominal wall itself in an austere environment. This article describes a series of patients with complex abdominal wall problems managed at the UK-led Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan. Contemporaneous review of a series of patients with complex abdominal wall injuries who presented to the Role 3 MTF between July and November 2012. Five patients with penetrating abdominal trauma associated with significant damage to the abdominal wall were included. All patients were managed using DCS principles, leaving the abdominal wall open at the end of the first procedure. Subsequent management of the abdominal wall was determined by a multidisciplinary team of general and plastic surgeons, intensivists and specialist nurses. The principles of management identified included minimising tissue loss on initial laparotomy by joining adjacent wounds and marginal debridement of dead tissue; contraction of the abdominal wall was minimised by using topical negative pressure dressing and dermal-holding sutures. Definitive closure was timed to allow oedema to settle and sepsis to be controlled. Closure techniques include delayed primary closure with traction sutures, components separation, and mesh closure with skin grafting. A daily multidisciplinary team discussion was invaluable for optimal decision making regarding the most appropriate means of abdominal closure. Dermal-holding sutures were particularly useful in preventing myostatic contraction of the abdominal wall. A simple flow chart was developed to aid decision making in these patients. This flow chart may prove especially useful in a resource-limited environment in which returning months or years later for closure of a large ventral hernia may not be possible. Published by the BMJ Publishing Group Limited. For permission to use
Howle, Chris R.; Spear, Abigail M.; Gazi, Ehsan; Crane, Nicole J.
In recent conflicts, battlefield injuries consist largely of extensive soft injuries from blasts and high energy projectiles, including gunshot wounds. Repair of these large, traumatic wounds requires aggressive surgical treatment, including multiple surgical debridements to remove devitalised tissue and to reduce bacterial load. Identifying those patients with wound complications, such as infection and impaired healing, could greatly assist health care teams in providing the most appropriate and personalised care for combat casualties. Candidate technologies to enable this benefit include the fusion of imaging and optical spectroscopy to enable rapid identification of key markers. Hence, a novel system based on IR negative contrast imaging (NCI) is presented that employs an optical parametric oscillator (OPO) source comprising a periodically-poled LiNbO3 (PPLN) crystal. The crystal operates in the shortwave and midwave IR spectral regions (ca. 1.5 - 1.9 μm and 2.4 - 3.8 μm, respectively). Wavelength tuning is achieved by translating the crystal within the pump beam. System size and complexity are minimised by the use of single element detectors and the intracavity OPO design. Images are composed by raster scanning the monochromatic beam over the scene of interest; the reflection and/or absorption of the incident radiation by target materials and their surrounding environment provide a method for spatial location. Initial results using the NCI system to characterise wound biopsies are presented here.
Covey, D C; Lurate, R B; Hatton, C T
The spectrum of wounding and treatment of forty-one patients with musculoskeletal blast injuries at a U.S. military field hospital in the former Yugoslavia was reviewed. Patients underwent wound exploration, irrigation, debridement, broad-spectrum antibiotic therapy, early fracture stabilization, and appropriate reconstructive surgery. Four patients developed wound infections. Two patients died as a result of their injuries (overall mortality 5 percent). There were three below-knee amputations and five other amputations (above-knee, ankle, midtarsal, partial forefoot, and finger). Three patients sustained lumbar burst fractures from mines that exploded under their vehicles, resulting in paraplegia in one case. Our patients underwent 112 surgical procedures, an average of 2.1 per patient. Twenty-two patients (54 percent) had other injuries or conditions in addition to their orthopaedic wounds. There were wide variations in the bone and soft tissue injuries caused by detonating ordnance, and the tissue damage was qualitatively different from that caused by gunshot wounds. Early debridement, leaving wounds open, and treatment with broad-spectrum antibiotics were important factors in wound healing to allow subsequent successful reconstructive surgery in an austere field setting.
Stoebner, Andrew A; Sachanandani, Neil S; Borschel, Gregory H
Nerve injuries from missile and gunshot wounds often produce significant disability, and their management is controversial. The role of the surgeon in cases of missile wounds with neurologic deficits is not well defined. Enhancing the trauma team's ability to recognize treatable nerve injuries will lead to improved outcomes. Further, raising awareness of the time-sensitive nature of these injuries will also improve results in these cases. We reviewed a consecutive series of 17 pediatric patients with peripheral nerve injuries caused by missile and gunshot wounds in a tertiary care children's hospital. We examined the indications for surgery, presence of associated injuries, mechanisms of injury, demographic characteristics and clinical outcomes. Urban victims were significantly more likely to have been intentionally assaulted than rural or suburban victims and they were also less likely to have completed follow-up care. High-energy weapons were more likely to require surgery compared with low-energy weapons. Patients presenting with tendon injuries were more likely to have a high-grade nerve injury requiring surgery. Patients presenting with tendon lacerations or high-energy mechanisms were significantly more likely to require surgery. Early exploration should be undertaken in cases where transection is likely to have occurred. Early decompression of common entrapment sites distal to repairs or injuries should be performed. Because follow-up is poor in this population, treatment should be prompt and thorough.
Elserry, Tarek; Anwer, Hesham; Esene, Ignatius Ngene
Background: A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option? Methods: We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge. Results: Five of the eight “stereotactic cases” had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine “neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery. Conclusion: Conventional craniotomy isn’t indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these
Detection and identification of organic and inorganic components of gunshot residue are well established within forensic chemistry because of highly characteristic and uncommon features of the products of ammunition discharge at the time and place of a shooting incident in comparison to other materials present in daily life of people. Both types of residue play an important role in establishing various circumstances of a shooting crime, though the most vital one concerns the possibility of relating a suspect with the activity of shooting. In this aspect, solid, inorganic particles, nowadays called characteristic, have been utilized. Their specific features result from the primer mixture composition, including compounds of heavy metals, lead, antimony, and barium, and from the extraordinarily dynamic conditions of their formation, taking place at the moment of the primer detonation. Scanning electron microscopy and X-ray microanalysis techniques proved to be necessary and sufficient to reveal the content and the spherical morphology of the particles for this purpose. Recently, the recommendation that the potential for lead exposure be minimized was followed in the production of ammunition cal. 9 mm Luger, 0.40 S&W, 0.380 Auto, and 0.38 Special. These modern types of ammunition expel less characteristic particles, the identification of which can be a challenge for the examiners. At least two solutions to strengthen the residue identity are taken into account: additional insights into the internal structure of inorganic particles, e.g., by means of electron backscattered diffraction and focused ion beam, as well as complementary examinations of organic residues with sensitive mass spectrometric techniques.
Showen, R. L.; Dunson, J. C.; Woodman, G.; Christopher, S.; Wilson, S.
Blast fishing (using explosives to catch fish) causes extensive damage to coral reefs, especially in the Coral Triangle in Southeast Asia. Subsistence fishermen and larger consortiums, often with criminal links, throw an explosive into a school of fish, killing all sea life within range. This unsustainable practice is becoming more prevalent, and threatens the protein supply of as many as a billion people. Ending blast fishing will require combined technical and societal methods aimed at both deterring the practice, and catching those responsible. Our work aims to significantly improve enforcement. We are re-purposing SST's ShotSpotter gunshot detection system, (trusted and valued by police around the world), substituting hydrophones for the present microphones. Using multilateration and trained human reviewers, the system can give prompt blast alerts, location data, and acoustic waveforms to law enforcement officials. We hope to establish a prototype system in Malaysia in 2015, and have already secured governmental approvals for installation and tests with local law enforcement. The Scubazoo media firm in Malaysia is working with resorts, dive operations, and celebrity sponsors, and is planning to produce videos to illustrate the severity of the problem to both governments and the public. Because there is little hard data concerning the prevalence of blast fishing in either marine protected areas or open waters, the system can also indicate to the world the actual blast rates and patterns of use. The Teng Hoi environmental NGO in Hong Kong showed in 2004 that acoustic waves from typical bombs propagate on the order of 20 km, so an underwater locator system with a small number of sensors can feasibly cover a sizable coral region. Our present plans are to mount sensors on piers, buoys, and boats, but if possible we would also like to integrate with other existing acoustic arrays to strengthen the fight against blast fishing.
Alvis-Miranda, Hernando Raphael; M. Rubiano, Andres; Agrawal, Amit; Rojas, Alejandro; Moscote-Salazar, Luis Rafael; Satyarthee, Guru Dutta; Calderon-Miranda, Willem Guillermo; Hernandez, Nidia Escobar; Zabaleta-Churio, Nasly
Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately, more prevalent condition in developing countries, with major armed conflicts which is still persisting, since the main trigger is violence at the national or state level. Management goals of CGI should focus on aggressive resuscitation and correction of coagulopathy; those with stable vital signs should undergo CT scan head at the earliest possible opportunity. Neuroimaging is vital for planning of surgical management, especially to determine the type of surgery, routes of the approach to the surgical target area and extraction of the impacted foreign bodies, however, surgical management is not always indicated. Although subset of such cases may be managed even with non-surgical management. The treatment comprises of immediate life salvaging resuscitative measures including control of the persistent bleeding, care of associated injury, management of raised intracranial pressure, prevention of cerebrospinal fistula formation by primary watertight dural repair and prevention of infection, through extensive debridement of contaminated, macerated or ischemic tissues; preservation of nervous tissue and restoration of anatomic structures through the hermetic sealing of dural and scalp defect. Recently, only few studies of craniocerebral penetrating injuries are published that too involving smaller patients sample sizes; although classic studies in the military and civil situation noticed associated relatively very high mortality and morbidity and psychological as well as economic impact on the affected individual, the family and the health system in providing ongoing care to the sufferers and society at large. Currently various measures are advocated with aim to reduce the incidence of CGI especially in civilian populations. It is highly necessary and immensely urgent to promote research in a neurocritical care of CGI to
Slade, Dominic Alexander James; Carlson, Gordon Lawrence
Key steps in managing patients with enterocutaneous fistulation and an abdominal wall defect include dealing effectively with abdominal sepsis and providing safe and effective nutritional support and skin care, then assessing intestinal and abdominal anatomy, before undertaking reconstructive surgery. The complexity, cost, and morbidity associated with such cases justifies creation of specialized centers in which gastroenterologic, hernia, and plastic surgical expertise, as well as experienced wound and stoma nursing and nutritional and psychological support, can be made available for patients with these challenging problems. Copyright © 2013 Elsevier Inc. All rights reserved.
Carrel, Alexis; Hartmann, Alice
1. A method for measuring the area of a wound not geometric in form is described. 2. The rate of cicatrization of a wound is greater at the beginning than at the end of the period of repair. It depends on the area rather than on the age of the wound. There is a constant relation between the size of a wound and the rate of cicatrization. The larger the wound the greater is the rate of cicatrization. Two wounds of different size have a tendency to become equal. 3. The rate is proportional to the area, but diminishes less rapidly than the area. 4. The process of contraction is the more important factor in the repair of a wound. Epidermization completes the work of contraction. After the wound is healed, the cicatrix as a rule expands. 5. The curve representing the diminution of the size of an aseptic wound while it cicatrizes is regular and geometric. PMID:19868052
Doebler, O; Spierer, R
A full-thickness defect of the abdominal wall is rare and may occur as a complication of extended abdominal surgery procedures. We report about a 69-year-old patient who was presented to our department with a full-thickness abdominal wall defect and a fully exposed collagen-mesh for reconstructive wound closure. 13 operations with resections of necrotic parts of the abdominal wall were performed following a complicated intraabdominal infection. After debridement and mesh explantation, closure of the remaining defect of the lower abdominal region was achieved by a cutaneous groin flap. Georg Thieme Verlag KG Stuttgart New York.
... plaque buildup causes the walls of the abdominal aorta to become weak and bulge outward like a ... treated? What is an abdominal aortic aneurysm? The aorta, the largest artery in the body, is a ...
Aliste, Marina; Chávez, Luis Guillermo
When a gun is fired, the majority of gunshot residues are deposited on the shooter's hands. But these residues disappear through contact with surfaces or washing. Therefore, the maximum time frame to find GSR on a suspect's hands is 8h. The mucus, inside of a nostril, forms a surface layer where they are trapped foreign particles. In this way, mucus inside of a gunshot suspect's nostrils could act like an adhesive medium to stick on it gaseous particles from a gunshot. In this study, the presence of GSR in nasal mucus and its residence time is examined. A new procedure for the sampling of possible gunshot residue accumulated in the nasal mucus is designed. Samples are taken with cotton swabs moistened with a solution of EDTA and, after an acid digestion, are analysed by graphite furnace atomic absorption spectrometry. In addition, samples of hands are taken for comparison purposes. GSR recovery has been successful. The concentration of GSR in nasal mucus is found to be lower than on the hands, but with a longer residence time. Thus, it is possible to expand the sampling time of a suspect also, as nasal mucus cannot be contaminated by handling weapons. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
González-Castaño, Francisco Javier; Alonso, Javier Vales; Costa-Montenegro, Enrique; López-Matencio, Pablo; Vicente-Carrasco, Francisco; Parrado-García, Francisco J; Gil-Castiñeira, Felipe; Costas-Rodríguez, Sergio
In this paper, we propose a solution for gunshot location in national parks. In Spain there are agencies such as SEPRONA that fight against poaching with considerable success. The DiANa project, which is endorsed by Cabaneros National Park and the SEPRONA service, proposes a system to automatically detect and locate gunshots. This work presents its technical aspects related to network design and planning. The system consists of a network of acoustic sensors that locate gunshots by hyperbolic multi-lateration estimation. The differences in sound time arrivals allow the computation of a low error estimator of gunshot location. The accuracy of this method depends on tight sensor clock synchronization, which an ad-hoc time synchronization protocol provides. On the other hand, since the areas under surveillance are wide, and electric power is scarce, it is necessary to maximize detection coverage and minimize system cost at the same time. Therefore, sensor network planning has two targets, i.e., coverage and cost. We model planning as an unconstrained problem with two objective functions. We determine a set of candidate solutions of interest by combining a derivative-free descent method we have recently proposed with a Pareto front approach. The results are clearly superior to random seeding in a realistic simulation scenario.
González-Castaño, Francisco Javier; Alonso, Javier Vales; Costa-Montenegro, Enrique; López-Matencio, Pablo; Vicente-Carrasco, Francisco; Parrado-García, Francisco J.; Gil-Castiñeira, Felipe; Costas-Rodríguez, Sergio
In this paper, we propose a solution for gunshot location in national parks. In Spain there are agencies such as SEPRONA that fight against poaching with considerable success. The DiANa project, which is endorsed by Cabaneros National Park and the SEPRONA service, proposes a system to automatically detect and locate gunshots. This work presents its technical aspects related to network design and planning. The system consists of a network of acoustic sensors that locate gunshots by hyperbolic multi-lateration estimation. The differences in sound time arrivals allow the computation of a low error estimator of gunshot location. The accuracy of this method depends on tight sensor clock synchronization, which an ad-hoc time synchronization protocol provides. On the other hand, since the areas under surveillance are wide, and electric power is scarce, it is necessary to maximize detection coverage and minimize system cost at the same time. Therefore, sensor network planning has two targets, i.e., coverage and cost. We model planning as an unconstrained problem with two objective functions. We determine a set of candidate solutions of interest by combining a derivative-free descent method we have recently proposed with a Pareto front approach. The results are clearly superior to random seeding in a realistic simulation scenario. PMID:22303135
Kolkutin, V V; Makarov, I Iu; Evteeva, I A
The authors discuss the objective potential of situational forensic medical expertise for the determination of the direction and the distance of a gunshot as well as the position of the gun in the shooter's hand. The use of fundamental theoretical propositions determining the essence of the form of expertise being considered is illustrated by an example from forensic medical practice.
Moravanský, Norbert; Rekeň, Viktor; Juříček, Ludvík; Zummerová, Anežka; Kováč, Peter
The question of handgun use in a city or densely populated aglomerations requires a highly practical level of solution to this issue, though with the knowledge of theoretical presumptions of wound ballistics of ricochet projectiles. The application of wound ballistics into the practice of a forensic pathologist, as well as a surgeon or a traumatologist, enables a good understanding of the dynamics of projectile penetration through anatomic structures of the human body. In forensic assessment, gunshot wounds of limbs are relatively frequent cases. By the integration of wound ballistics principles into the research of gunshot wounds, it is also possible to establish, whether the projectile entered into the anatomic structures under direct trajectory steadily or whether through the course of its trajectory, before reaching the human body, it firstly contacted a particular object in the space, i. e. whether the injury could have been caused by a ricochet projectile. In connection with unclear gunshot wounds and their morphological image, it is necessary to consider the possibility of the effects of a ricochet projectile, especially when persons are injured accidentally. The daily practice of the officers of the Police Corps of the Slovak Republic essentially enhances the necessity of being informed about the behaviour of parametrically designated ricochet projectiles in a ballistic experiment with the use of a model of a built-up area in a town, with typical materials and surfaces of objects in between and a model of a human limb part as a potential target of an uncontrolled ricochet projectile. The proposed design of the situation is undoubtedly of an enormous significance, even when forensically evaluating the morphological consequences of ricochet projectiles. By the application of results of such experiments and their final comparison, when different types of projectiles are used, it is also possible to contribute to the experts groundwork in the process of
Powers, Jennifer G; Higham, Catherine; Broussard, Karen; Phillips, Tania J
In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
Amyloidosis - abdominal wall fat pad biopsy; Abdominal wall biopsy; Biopsy - abdominal wall fat pad ... most common method of taking an abdominal wall fat pad biopsy . The health care provider cleans the ...
Belmont, Philip J; Thomas, Dimitri; Goodman, Gens P; Schoenfeld, Andrew J; Zacchilli, Michael; Burks, Rob; Owens, Brett D
A prospective, longitudinal analysis of musculoskeletal combat injuries sustained by a large combat-deployed maneuver unit has not previously been performed. A detailed description of the musculoskeletal combat casualty care statistics, distribution of wounds, and mechanisms of injury incurred by a US Army Brigade Combat Team during "The Surge" phase of Operation Iraqi Freedom was performed using a centralized casualty database and an electronic medical record system. Among the 4,122 soldiers deployed, there were 242 musculoskeletal combat wounds in 176 combat casualties. The musculoskeletal combat casualty rate for the Brigade Combat Team was 34.2 per 1,000 soldier combat-years. Spine, pelvis, and long bone fractures comprised 55.9% (33 of 59) of the total fractures sustained in combat. Explosions accounted for 80.7% (142 of 176) of all musculoskeletal combat casualties. Musculoskeletal combat casualty wound incidence rates per 1,000 combat-years were as follows: major amputation, 2.1; minor amputation, 0.6; open fracture, 5.0; closed fracture, 6.4; and soft-tissue/neurovascular injury, 32.8. Among musculoskeletal combat casualties, the likelihood of a gunshot wound causing an open fracture was significantly greater (45.8% [11 of 24]) when compared with explosions (10.6% [15 of 142]) (p = 0.0006). Long bone amputations were more often caused by explosive mechanisms than gunshot wounds. A large burden of complex orthopedic injuries has resulted from the combat experience in Operation Iraqi Freedom. This is because of increased enemy reliance on explosive devices, the use of individual and vehicular body armor, and improved survivability of combat-injured soldiers.
This booklet offers guidelines on how to care for trees to keep them healthy and to protect them from wounds. It also prescribes ways to prevent, recognize, and minimize damage by decay that most often sets in after tree wounding.
... wound because the area is cleaned with an antibacterial solution before surgery — and it's in a place ... may be frustrating having to hold back on activities like sports while a wound heals. But if ...
Ozer, Mustafa Tahir; Oğünç, Gökhan; Eryilmaz, Mehmet; Yiğit, Taner; Menteş, Mustafa Oner; Dakak, Mehmet; Uzar, Ali Ihsan; Oner, Köksal
Effects of various types and diameters of guns and related treatment principles are different. Our study was performed to experimentally demonstrate the effects of different gunshots in body tissues. 9x19 mm hand-gun and 7.62x51 mm G-3 infantry rifle were used in the study. Injury models were created through hand-gun and rifle shootings at isolated soft tissue, lower extremity, liver and intestine tissue simulants made of ballistic candle. High-speed cameras were used to capture 1000 frames per second. Images were examined and wound mechanisms were evaluated. It was observed that the colon content distributed more within the surrounding tissues by the rifle shootings comparing with hand-gun shootings and could be an infection source due to the large size of the cavity in the colon. Especially when the bullets hitting the bone were investigated, it was seen that much more tissue injury occurs with high speed bullets due to bullet deformation and fragmentation. However, no significant difference was found between the effect of hand-gun and rifle bullets passing through the extremity without hitting the bone. To know the type of the gun that caused the injury and its characteristics will allow to estimate severity and size of the injury before the treatment and to focus on different alternatives of treatment. Therefore, use of appropriate models is required in experimental studies.
... your doctor recommends. Hold the syringe 1 to 6 inches (2.5 to 15 centimeters) away from the wound. Spray hard enough into the wound to wash away drainage and discharge. Use a clean soft, dry cloth or piece of gauze to carefully pat the wound dry. ...
James W. Walters
Most hardwood diseases are spread by spores that are carried either by wind or insects. The spores enter into the host tree through natural wounds (fire scars, bark splits, sunscald, cankers, and branch stubs) or artificial wounds (bark carving, improper pruning, logging damage). Fresh wounds attract certain insects that can carry spores into the exposed part of the...
Edwards, Ruth; Harding, Keith G
Wound healing is a complex process with many potential factors that can delay healing. There is increasing interest in the effects of bacteria on the processes of wound healing. All chronic wounds are colonized by bacteria, with low levels of bacteria being beneficial to the wound healing process. Wound infection is detrimental to wound healing, but the diagnosis and management of wound infection is controversial, and varies between clinicians. There is increasing recognition of the concept of critical colonization or local infection, when wound healing may be delayed in the absence of the typical clinical features of infection. The progression from wound colonization to infection depends not only on the bacterial count or the species present, but also on the host immune response, the number of different species present, the virulence of the organisms and synergistic interactions between the different species. There is increasing evidence that bacteria within chronic wounds live within biofilm communities, in which the bacteria are protected from host defences and develop resistance to antibiotic treatment. An appreciation of the factors affecting the progression from colonization to infection can help clinicians with the interpretation of clinical findings and microbiological investigations in patients with chronic wounds. An understanding of the physiology and interactions within multi-species biofilms may aid the development of more effective methods of treating infected and poorly healing wounds. The emergence of consensus guidelines has helped to optimize clinical management.
Successful wound management requires appropriate evaluation of the wound at the time of initial physical examination, an all throughout the healing process. Factors affecting wound healing need to be identified though a complete patient history and addressed to ensure proper healing. The clinician must have current knowledge of topical medications and bandages available and their clinical applications according to the stage of healing. It is essential to remember that wounds are painful; therefore, analgesics should be administered to render the animal pain-free during wound cleaning, debridement, bandaging, and surgical procedures.
Richards, Jean; Lickey, Adrienne; Sleeman, Jonathan M
A retrospective study was conducted to identify the epidemiologic factors associated with gunshot injuries in raptors presented to the Wildlife Center of Virginia from 1993 to 2002. Of the 3,156 raptors admitted, 118 raptors (3.7%), representing 15 species, were admitted with gunshot trauma as the primary cause of morbidity and mortality. The majority of cases consisted of four species: red-tailed hawk (Buteo jamaicensis; 47%), red-shouldered hawk (Buteo lineatus; 14%), turkey vulture (Cathartes aura; 10%), and bald eagle (Haliaeetus leucocephalus; 8%). For species with greater than 40 admissions during the study period, the proportion of gunshot trauma of all causes of morbidity and mortality ranged from <1% to 11%. Greater numbers of raptors with gunshot trauma were admitted during the fall and winter months (75%) compared with the spring and summer (25%). A significant decrease in the absolute number of gunshot cases per year was observed over the time period studied. The population-level effect of gunshot trauma is unknown for these species; however, it appears to be minor compared with other causes of morbidity and mortality.
History and recent developments of the concept of wounded hadronic constituents are summarized, with the special attention to the quark-diquark model of particle production in nucleon-nucleon and nucleus-nucleus collisions.
Wound Limb Salvage Program WRAMC/NNMC Inpatient Care Wound and Ostomy NNMC and WRAMC Outpatient Care 2 Clinics over 400 complex encounters NNMC and... Ostomy Wound care Skin Care Cleansers Research / EBP Pressure ulcer protocol CPG development Wound education research grant WRNMMC wound care formulary...Algorithm Sibbald, Orstead, Schultz, Coutts, Keast. Preparing the Wound Bed – Focus on Infection and Inflammation. Ostomy Wound Manag 49:24-51
Iyer, Rajalakshmi; Nallasamy, Karthi
Abdominal pain is one of the common symptoms reported by children in urgent care clinics. While most children tend to have self-limiting conditions, the treating pediatrician should watch out for underlying serious causes like intestinal obstruction and perforation peritonitis, which require immediate referral to an emergency department (ED). Abdominal pain may be secondary to surgical or non-surgical causes, and will differ as per the age of the child. The common etiologies for abdominal pain presenting to an urgent care clinic are acute gastro-enteritis, constipation and functional abdominal pain; however, a variety of extra-abdominal conditions may also present as abdominal pain. Meticulous history taking and physical examination are the best tools for diagnosis, while investigations have a limited role in treating benign etiologies.
Filipović, Marinko; Novinscak, Tomislav
Chronic ulcers have adverse effects on the patient quality of life and productivity, thus posing financial burden upon the healthcare system. Chronic wound healing is a complex process resulting from the interaction of the patient general health status, wound related factors, medical personnel skill and competence, and therapy related products. In clinical practice, considerable improvement has been made in the treatment of chronic wounds, which is evident in the reduced rate of the severe forms of chronic wounds in outpatient clinics. However, in spite of all the modern approaches, efforts invested by medical personnel and agents available for wound care, numerous problems are still encountered in daily practice. Most frequently, the problems arise from inappropriate education, of young personnel in particular, absence of multidisciplinary approach, and inadequate communication among the personnel directly involved in wound treatment. To perceive them more clearly, the potential problems or complications in the management of chronic wounds can be classified into the following groups: problems mostly related to the use of wound coverage and other etiology related specificities of wound treatment; problems related to incompatibility of the agents used in wound treatment; and problems arising from failure to ensure aseptic and antiseptic performance conditions.
... ency/presentations/100049.htm Abdominal exploration - series—Normal ... intestine (jejunum and ileum), the large intestine (colon), the liver, the spleen, the gallbladder, the pancreas, the uterus, ...
Ghoraba, Hammouda Hamdy; Elgouhary, Sameh Mohamed; Mansour, Hosam Osman; Abdel-Fattah, Hitham Mamoun; Heikal, Mohamed Amin; Elgemaey, Emad Mohamed
To evaluate the feasibility and safety of silicone oil (SO) removal in cases of gunshot perforating eye injuries (PEI). A retrospective, consecutive, interventional study from medical records regarding cases of gunshot PEI during the periods of Egyptian political instability (January 2011 until December 2013). The main outcomes were to evaluate the feasibility of SO removal in cases of gunshot PEI and management of retinal detachment (RD) after SO removal in such cases. One hundred ninety-six eyes of 193 patients were reviewed. SO was removed in 72 eyes of 70 patients (36.7%). After SO removal, five eyes (6.9%) developed RD. One case refused any other intervention. RD in the remaining four cases was treated with revision surgery and SO reinjection. The retina remained stable throughout follow-up. None of the eyes developed phthisis bulbi after SO removal. Mean follow-up after SO removal was 10.86 months (range: 3 months to 30 months). Mean follow-up after management of RD after SO removal was 17.7 months (range: 13 months to 21 months). Patients aged younger than 20 years were associated with extensive fibrous proliferation, which might affect the safety profile of SO removal in cases of gunshot PEI. Rate of RD after SO removal in cases of apparent retinal stability and localized fibrous proliferation was 6.9%. Retinal detachment after SO removal in such cases can be treated with revision surgery and SO reinjection. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:242-250.]. Copyright 2017, SLACK Incorporated.
Okonkwo, Uzoagu A; DiPietro, Luisa A
Diabetes Mellitus Type II (DM2) is a growing international health concern with no end in sight. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation. In skin wound healing, which has definite, orderly phases, diabetes leads to improper function at all stages. While the etiology of chronic, non-healing diabetic wounds is multi-faceted, the progression to a non-healing phenotype is closely linked to poor vascular networks. This review focuses on diabetic wound healing, paying special attention to the aberrations that have been described in the proliferative, remodeling, and maturation phases of wound angiogenesis. Additionally, this review considers therapeutics that may offer promise to better wound healing outcomes.
Guo, S.; DiPietro, L.A.
Wound healing, as a normal biological process in the human body, is achieved through four precisely and highly programmed phases: hemostasis, inflammation, proliferation, and remodeling. For a wound to heal successfully, all four phases must occur in the proper sequence and time frame. Many factors can interfere with one or more phases of this process, thus causing improper or impaired wound healing. This article reviews the recent literature on the most significant factors that affect cutaneous wound healing and the potential cellular and/or molecular mechanisms involved. The factors discussed include oxygenation, infection, age and sex hormones, stress, diabetes, obesity, medications, alcoholism, smoking, and nutrition. A better understanding of the influence of these factors on repair may lead to therapeutics that improve wound healing and resolve impaired wounds. PMID:20139336
Hrynyk, Michael; Neufeld, Ronald J
Skin is a dynamic and complex organ that relies on the interaction of different cell types, biomacromolecules and signaling molecules. Injury triggers a cascade of events designed to quickly restore skin integrity. Depending on the size and severity of the wound, extensive physiological and metabolic changes can occur, resulting in impaired wound healing and increased morbidity resulting in higher rates of death. While wound dressings provide a temporary barrier, they are inherently incapable of significantly restoring metabolic upsets, post-burn insulin resistance, and impaired wound healing in patients with extensive burns. Exogenous insulin application has therefore been investigated as a potential therapeutic intervention for nearly a century to improve wound recovery. This review will highlight the important achievements that demonstrate insulin's ability to stimulate cellular migration and burn wound recovery, as well as providing a perspective on future therapeutic applications and research directions. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.
Okonkwo, Uzoagu A.; DiPietro, Luisa A.
Diabetes Mellitus Type II (DM2) is a growing international health concern with no end in sight. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation. In skin wound healing, which has definite, orderly phases, diabetes leads to improper function at all stages. While the etiology of chronic, non-healing diabetic wounds is multi-faceted, the progression to a non-healing phenotype is closely linked to poor vascular networks. This review focuses on diabetic wound healing, paying special attention to the aberrations that have been described in the proliferative, remodeling, and maturation phases of wound angiogenesis. Additionally, this review considers therapeutics that may offer promise to better wound healing outcomes. PMID:28671607
Guo, S; Dipietro, L A
Wound healing, as a normal biological process in the human body, is achieved through four precisely and highly programmed phases: hemostasis, inflammation, proliferation, and remodeling. For a wound to heal successfully, all four phases must occur in the proper sequence and time frame. Many factors can interfere with one or more phases of this process, thus causing improper or impaired wound healing. This article reviews the recent literature on the most significant factors that affect cutaneous wound healing and the potential cellular and/or molecular mechanisms involved. The factors discussed include oxygenation, infection, age and sex hormones, stress, diabetes, obesity, medications, alcoholism, smoking, and nutrition. A better understanding of the influence of these factors on repair may lead to therapeutics that improve wound healing and resolve impaired wounds.
my judgment, immediate skin graft closure after 1963. excision of a large burn is similar to closure of a celiotomy in 8. Haxten, H.: The absorption of...Surg. Gynecol. Obstet., 129: preventing skin graft disruption in such cases. Rather than the 758-760, 1969. usual 4 to 5 days required for solid...closure: A tion is necessary to produce a near 100% take when skin graft systems approach. Am. J. Surg., 131: 476-480, 1976.15. Mayo, C. W., Lee, M. J
Usta, Taner A.; Ozyurek, Sefik E.; Gundogdu, Elif C.
We present a rare case with gossypiboma following cesarean section which led to uterine wound dehiscence. A 30-year-old woman had been submitted to an emergency cesarean section 4 months previously at another hospital. Clinical and ultrasound findings revealed a large intra-abdominal mass and diffuse peritonitis. At laparotomy, a gossypiboma causing an abscess and uterine wound dehiscence with necrosis of the margins was detected. We performed repetitive wound debridements under broad-spectrum antibiotic cover and eventually resutured the incision. Although hysterectomy has so far been the choice of treatment in the literature once a uterine wound dehiscence had occurred, it was possible in this case to preserve the uterus. PMID:24106624
Sansare, K; Khanna, V; Karjodkar, F
Gunshot injuries are an emerging form of trauma that oral radiologists increasingly have to deal with. There are two main types of gunshot injuries: high-velocity and low-velocity bullet injuries. The outcome of high-velocity gunshot injury is usually fatal; however, a non-fatal low-velocity injury to the maxillofacial region is more likely to be encountered by the oral and maxillofacial radiologist. It is therefore important to up-to-date knowledge of ballistic science and its implications in the field of maxillofacial radiology. The ability of oral and maxillofacial radiologists to predict the missile trajectory will aid the assessment and localization of the damage caused by the bullet and its splinters. Predicting the missile trajectory may also be of help to law enforcement agencies and forensic scientists in determining the type of firearm used and direction of fire. This article, which examines two cases, attempts to highlight to the oral radiologist this emerging form of trauma and its implications. PMID:21159916
Sansare, K; Khanna, V; Karjodkar, F
Gunshot injuries are an emerging form of trauma that oral radiologists increasingly have to deal with. There are two main types of gunshot injuries: high-velocity and low-velocity bullet injuries. The outcome of high-velocity gunshot injury is usually fatal; however, a non-fatal low-velocity injury to the maxillofacial region is more likely to be encountered by the oral and maxillofacial radiologist. It is therefore important to up-to-date knowledge of ballistic science and its implications in the field of maxillofacial radiology. The ability of oral and maxillofacial radiologists to predict the missile trajectory will aid the assessment and localization of the damage caused by the bullet and its splinters. Predicting the missile trajectory may also be of help to law enforcement agencies and forensic scientists in determining the type of firearm used and direction of fire. This article, which examines two cases, attempts to highlight to the oral radiologist this emerging form of trauma and its implications.
Kirkpatrick, A W; Nickerson, D; Roberts, D J; Rosen, M J; McBeth, P B; Petro, C C; Berrevoet, Frederik; Sugrue, M; Xiao, Jimmy; Ball, C G
Reconstruction with reconstitution of the container function of the abdominal compartment is increasingly being performed in patients with massive ventral hernia previously deemed inoperable. This situation places patients at great risk of severe intra-abdominal hypertension and abdominal compartment syndrome if organ failure ensues. Intra-abdominal hypertension and especially abdominal compartment syndrome may be devastating systemic complications with systematic and progressive organ failure and death. We thus reviewed the pathophysiology and reported clinical experiences with abnormalities of intra-abdominal pressure in the context of abdominal wall reconstruction. Bibliographic databases (1950-2015), websites, textbooks, and the bibliographies of previously recovered articles for reports or data relating to intra-abdominal pressure, intra-abdominal hypertension, and the abdominal compartment syndrome in relation to ventral, incisional, or abdominal hernia repair or abdominal wall reconstruction. Surgeons should thus consider and carefully measure intra-abdominal pressure and its resultant effects on respiratory parameters and function during abdominal wall reconstruction. The intra-abdominal pressure post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate intra-abdominal pressure rise after abdominal wall reconstruction including temporizing paralysis of the musculature either temporarily or semi-permanently, pre-operative progressive pneumoperitoneum, permanently removing visceral contents, or surgically releasing the musculature to increase the abdominal container volume. In patients without complicating shock and inflammation, and in whom the abdominal wall anatomy has been so functionally adapted to maximize compliance, intra-abdominal hypertension may be transient and tolerable. Intra-abdominal hypertension/abdominal compartment syndrome in the specific setting of
Zhao, Ruilong; Liang, Helena; Clarke, Elizabeth; Jackson, Christopher; Xue, Meilang
Non-healing chronic wounds present a major biological, psychological, social, and financial burden on both individual patients and the broader health system. Pathologically extensive inflammation plays a major role in the disruption of the normal healing cascade. The causes of chronic wounds (venous, arterial, pressure, and diabetic ulcers) can be examined through a juxtaposition of normal healing and the rogue inflammatory response created by the common components within chronic wounds (ageing, hypoxia, ischaemia-reperfusion injury, and bacterial colonisation). Wound bed care through debridement, dressings, and antibiotics currently form the basic mode of treatment. Despite recent setbacks, pharmaceutical adjuncts form an interesting area of research.
Chittoria, Ravi K.
The escalating physiological, psychological, social and financial burdens of wounds and wound care on patients, families and society demand the immediate attention of the health care sector. Many forces are affecting the changes in health care provision for patients with chronic wounds, including managed care, the limited number of wound care therapists, an increasingly ageing and disabled population, regulatory and malpractice issues, and compromised care. The physician is also faced with a number of difficult issues when caring for chronic wound patients because their conditions are time consuming and high risk, represent an unprofitable part of care practice and raise issues of liability. Telemedicine enhances communication with the surgical wound care specialist. Digital image for skin lesions is a safe, accurate and cost-effective referral pathway. The two basic modes of telemedicine applications, store and forward (asynchronous transfer) and real-time transmission (synchronous transfer, e.g. video conference), are utilized in the wound care setting. Telemedicine technology in the hands of an experienced physician can streamline management of a problem wound. Although there is always an element of anxiety related to technical change, the evolution of wound care telemedicine technology has demonstrated a predictable maturation process. PMID:23162242
Zhao, Ruilong; Liang, Helena; Clarke, Elizabeth; Jackson, Christopher; Xue, Meilang
Non-healing chronic wounds present a major biological, psychological, social, and financial burden on both individual patients and the broader health system. Pathologically extensive inflammation plays a major role in the disruption of the normal healing cascade. The causes of chronic wounds (venous, arterial, pressure, and diabetic ulcers) can be examined through a juxtaposition of normal healing and the rogue inflammatory response created by the common components within chronic wounds (ageing, hypoxia, ischaemia-reperfusion injury, and bacterial colonisation). Wound bed care through debridement, dressings, and antibiotics currently form the basic mode of treatment. Despite recent setbacks, pharmaceutical adjuncts form an interesting area of research. PMID:27973441
Brand, Henk S; Ligtenberg, Antoon J M; Veerman, Enno C I
Oral wounds heal faster and with less scar formation than skin wounds. One of the key factors involved is saliva, which promotes wound healing in several ways. Saliva creates a humid environment, thus improving the survival and functioning of inflammatory cells that are crucial for wound healing. In addition, saliva contains several proteins which play a role in the different stages of wound healing. Saliva contains substantial amounts of tissue factor, which dramatically accelerates blood clotting. Subsequently, epidermal growth factor in saliva promotes the proliferation of epithelial cells. Secretory leucocyte protease inhibitor inhibits the tissue-degrading activity of enzymes like elastase and trypsin. Absence of this protease inhibitor delays oral wound healing. Salivary histatins in vitro promote wound closure by enhancing cell spreading and cell migration, but do not stimulate cell proliferation. A synthetic cyclic variant of histatin exhibits a 1,000-fold higher activity than linear histatin, which makes this cyclic variant a promising agent for the development of a new wound healing medication. Conclusively, recognition of the many roles salivary proteins play in wound healing makes saliva a promising source for the development of new drugs involved in tissue regeneration.
Innovation in medicine requires unique partnerships between academic research, biotech or pharmaceutical companies, and health-care providers. While innovation in medicine has greatly increased over the past 100 years, innovation in wound care has been slow, despite the fact that chronic wounds are a global health challenge where there is a need for technical, process and social innovation. While novel partnerships between research and the health-care system have been created, we still have much to learn about wound care and the wound-healing processes.
Borioni, Raoul; Garofalo, Mariano; De Paulis, Ruggero; Nardi, Paolo; Scaffa, Raffaele; Chiariello, Luigi
Isolated abdominal aortic dissections are rare events. Their anatomic and clinical features are different from those of atherosclerotic aneurysms. We report 4 cases of isolated abdominal aortic dissection that were successfully treated with surgical or endovascular intervention. The anatomic and clinical features and a review of the literature are also presented. PMID:15902826
Xing, Liyu; Franz, Michael G.; Marcelo, Cynthia L.; Smith, Charlotte A.; Marshall, Vivienne S.; Robson, Martin C.
Objective: Acute wound failure is a common complication following surgical procedures and trauma. Laparotomy wound failure leads to abdominal dehiscence and incisional hernia formation. Delayed recovery of wound-breaking strength is one mechanism for laparotomy wound failure. Early fascial wounds are relatively acellular, and there is a delay in the appearance of acute wound growth factors and cytokines. The objective of this study was to accelerate and improve laparotomy wound healing using amnion-derived multipotent cells (AMPs). AMPs' nonimmunogenic phenotype and relative abundance support its role as a cell therapy. Methods: AMPs were injected into the load-bearing layer of rat abdominal walls prior to laparotomy, and cell viability was confirmed. Wound mechanical properties were measured over 28 days. The incidence and severity of laparotomy wound failure was measured in an incisional hernia model. Results: AMP cells were viable in laparotomy wounds for at least 28 days and did not migrate to other tissues. Laparotomy wound-breaking strength was increased by postoperative day 7 following AMP therapy. AMP therapy reduced the incidence of hernia formation and the size of hernia defects. Histology suggested stimulated wound fibroplasia and angiogenesis. Conclusions: AMP cell therapy reduces the incidence of laparotomy wound failure by accelerating the recovery of wound-breaking strength. This results in fewer incisional hernias and smaller hernia defects. PMID:18091982
Akkol, Esra Küpeli; Koca, Ufuk; Pesin, Ipek; Yilmazer, Demet
Achillea species are widely used for diarrhea, abdominal pain, stomachache and healing of wounds in folk medicine. To evaluate the wound healing activity of the plant, extracts were prepared with different solvents; hexane, chloroform, ethyl acetate and methanol, respectively from the roots of Achillea biebersteinii. Linear incision by using tensiometer and circular excision wound models were employed on mice and rats. The wound healing effect was comparatively evaluated with the standard skin ointment Madecassol. The n-hexane extract treated groups of animals showed 84.2% contraction, which was close to contraction value of the reference drug Madecassol (100%). On the other hand the same extract on incision wound model demonstrated a significant increase (40.1%) in wound tensile strength as compared to other groups. The results of histoptological examination supported the outcome of linear incision and circular excision wound models as well. The experimental data demonstrated that A. biebersteinii displayed remarkable wound healing activity. PMID:19546149
Lassandro, Francesco; Iasiello, Francesca; Pizza, Nunzia Luisa; Valente, Tullio; Stefano, Maria Luisa Mangoni di Santo; Grassi, Roberto; Muto, Roberto
Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately 4%-5%. They are distinguished in external, diaphragmatic and internal hernias on the basis of their localisation. Groin hernias are the most common with a prevalence of 75%, followed by femoral (15%) and umbilical (8%). There is a higher prevalence in males (M:F, 8:1). Diagnosis is usually made on physical examination. However, clinical diagnosis may be difficult, especially in patients with obesity, pain or abdominal wall scarring. In these cases, abdominal imaging may be the first clue to the correct diagnosis and to confirm suspected complications. Different imaging modalities are used: conventional radiographs or barium studies, ultrasonography and Computed Tomography. Imaging modalities can aid in the differential diagnosis of palpable abdominal wall masses and can help to define hernial contents such as fatty tissue, bowel, other organs or fluid. This work focuses on the main radiological findings of abdominal herniations. PMID:21860678
Chobola, M; Sobotka, L; Ferko, A; Oberreiter, M; Kaska, M; Motycka, V; Páral, J; Mottl, R
Wound dehiscence complicated by gastrointestinal (GI) fistula to belong ,,abdominal catastrophe". Therapy is prolonged and connected with high morbidity and mortality rate. In the period from October 2006 to July 2009 we performed 12 reconstructive surgical procedures on gastrointestinal tract in patients with abdominal catastrophe. Treatment of 12 consecutive patients (9 men, 3 women) was managed according to a standardize protocol. The protocol consists of treatment of septic complications, optimisation of nutritional state, special wound procedures, diagnosis of gastrointestinal fistulas and GI tract, timing of surgical procedures, reconstruction of GI tract and postoperative care. Reconstructive surgery of GI tract was successful on 11 patients. One patient developed recurrence of early GI fistula. In four patients we let open abdomen to heal per secundam. We observed no deaths after operation. With regard to complex character of therapy of abdominal catastrophe there is a need of multidisciplinary approach. Considering long-lasting and expensive therapy there is logical step to concentrate these patients into special centres which are experienced, equipped and their staff is trained in treatment of such a seriously impaired patients.
Shehu, B B; Ismail, N J; Hassan, I; Mahmud, M R; Lasseini, A
A male fetus was extruded from the uterus following multiple lower abdominal stab wounds to the mother. He was brought to the emergency room at 8 hours of age. He had sustained a compound skull fracture with brain contusion. There was no neurological deficit. Debridement and primary wound closure were undertaken. His mother had multiple lacerations to the uterus and a laceration of the fundus of the bladder. Following resuscitation, she had repair of the uterus and bladder and made an uneventful recovery. At 3 years of age, the boy is developing normally.
Du Noüy, P. Lecomte
The cicatrization of sterile wounds may be studied in the same way as an ordinary physicochemical phenomenon. It is possible, therefore, to express the law of cicatrization by a mathematical equation as soon as an accurate measure of the wound can be obtained. By means of the equation, a curve is obtained which represents the theoretical evolution of the cicatrization of a wound. This curve, being an expression of what should happen on a normal wound, healing aseptically, on a normal man, is a daily point of comparison to what appears actually on the observed wound, and allows one to study accurately the fluctuations of cicatrization on a given individual, and the action of different dressings and antiseptic substances PMID:19868053
Volk, Angela; Zebda, Mohamed; Abdelgawad, Amr A
The purpose of this study was to describe our experience in treatment of pediatric patient presenting with pedal puncture wound to our level I trauma center and describe our results for the need for hospitalization and/or surgery for these patients. Children and adolescents 18 years and younger presenting with pedal puncture wounds from September 2009 to December of 2013 were retrospectively studied. Exclusion criteria included adult patients, wounds related to animal bites, lacerations associated with a motor vehicle collision or all-terrain vehicle accidents, gunshot wounds, degloving injuries, or injuries resulting in complex lacerations to the foot. A total of 147 children presented to emergency department (ED) with a pedal puncture wound. Average age was 9.8 years. Prophylactic antibiotic therapy was administered in 107 cases (72.8%). Fifteen patients (10%) were treated with intravenous or intramuscular antibiotics in the ED or after hospital admission, 81 patients (55%) were treated with oral medications (prescribed for them to be taken after discharge), and 35 patients (24%) received topical antibiotic treatment. Of the 147 patients included in the study, 9 patients (6%) required the need for hospitalization. Two patients were admitted for parenteral antibiotic treatment only, and 7 patients required formal surgical debridement in the operating room in addition to parenteral antibiotic therapy. The majority of pediatric patients with pedal puncture wounds were treated in the ED with only a small percentage of patients requiring admission for either parenteral antibiotic treatment or formal surgical debridement.
Koop, Herbert; Koprdova, Simona; Schürmann, Christine
Chronic abdominal wall pain is a poorly recognized clinical problem despite being an important element in the differential diagnosis of abdominal pain. This review is based on pertinent articles that were retrieved by a selective search in PubMed and EMBASE employing the terms "abdominal wall pain" and "cutaneous nerve entrapment syndrome," as well as on the authors' clinical experience. In 2% to 3% of patients with chronic abdominal pain, the pain arises from the abdominal wall; in patients with previously diagnosed chronic abdominal pain who have no demonstrable pathological abnormality, this likelihood can rise as high as 30% . There have only been a small number of clinical trials of treatment for this condition. The diagnosis is made on clinical grounds, with the aid of Carnett's test. The characteristic clinical feature is strictly localized pain in the anterior abdominal wall, which is often mischaracterized as a "functional" complaint. In one study, injection of local anesthesia combined with steroids into the painful area was found to relieve pain for 4 weeks in 95% of patients. The injection of lidocaine alone brought about improvement in 83-91% of patients. Long-term pain relief ensued after a single lidocaine injection in 20-30% of patients, after repeated injections in 40-50% , and after combined lidocaine and steroid injections in up to 80% . Pain that persists despite these treatments can be treated with surgery (neurectomy). Chronic abdominal wall pain is easily diagnosed on physical examination and can often be rapidly treated. Any physician treating patients with abdominal pain should be aware of this condition. Further comparative treatment trials will be needed before a validated treatment algorithm can be established.
... are, or may be, pregnant. Alternative Names Abdominal film; X-ray - abdomen; Flat plate; KUB x-ray ... Guidelines Viewers & Players MedlinePlus Connect for EHRs For Developers U.S. National Library of Medicine 8600 Rockville Pike, ...
... this problem include: Smoking High blood pressure Male gender Genetic factors An abdominal aortic aneurysm is most ... body from an aortic aneurysm, you will need surgery right away. If the aneurysm is small and ...
Computed tomography scan - abdomen; CT scan - abdomen; CT abdomen and pelvis ... An abdominal CT scan makes detailed pictures of the structures inside your belly very quickly. This test may be used to look ...
... blood clots to the lungs) Abdominal or chest wall pain: Shingles (herpes zoster infection) Costochondritis (inflammation of ... or tumors), fat (evidence of impaired digestion and absorption of food), and the presence of germs. X- ...
Abdominal ultrasound is a scanning technique used to image the interior of the abdomen. Like the X-ray, MRI, ... it has its place as a diagnostic tool. Ultrasound scans use high frequency sound waves to produce ...
Vijayaraghavan, S Boopathy; Palanivelu, Chinnusamy; Sendhilkumar, Karuppusamy; Parthasarathi, Ramakrishnan
An abdominal cocoon is a rare condition in which the small bowel is encased in a membrane. The diagnosis is usually established at surgery. Here we describe the sonographic features of this condition.
Jena, Anupam B; Sun, Eric C; Prasad, Vinay
Recent mass shootings in the U.S. have reignited the important public health debate concerning measures to decrease the epidemic of gun violence. Editorialists and gun lobbyists have criticized the recent focus on gun violence, arguing that gun-related homicide rates have been stable in the last decade. While true, data from the U.S. Centers for Disease Control and Prevention also demonstrate that although gun-related homicide rates were stable between 2002 and 2011, rates of violent gunshot injuries increased. These seemingly paradoxical trends may reflect the declining lethality of gunshot injuries brought about by surgical advances in the care of the patient with penetrating trauma. Focusing on gun-related homicide rates as a summary statistic of gun violence, rather than total violent gunshot injuries, can therefore misrepresent the rising epidemic of gun violence in the U.S.
Utiyama, Edivaldo Massazo; Pflug, Adriano Ribeiro Meyer; Damous, Sérgio Henrique Bastos; Rodrigues, Adilson Costa; Montero, Edna Frasson de Souza; Birolini, Claudio Augusto Vianna
to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.
Government as part of that person’s official duties. Deliver~~ by Publishing Technology to: Waiter Reed Army Institute of R~l!il>~~vTP:11~1~:S6;!4!B1...develop a predictive model, which could serve as a clinical decision support tool in the management of complex war wounds. Bayesian belief networks...decisions regarding the surgical management of wounds and estimate overall out- come of patients on the basis of casualty-specific factors in wounded
Brand, Martin; Grieve, Andrew
Penetrating abdominal trauma occurs when the peritoneal cavity is breached. Routine laparotomy for penetrating abdominal injuries began in the 1800s, with antibiotics first being used in World War II to combat septic complications associated with these injuries. This practice was marked with a reduction in sepsis-related mortality and morbidity. Whether prophylactic antibiotics are required in the prevention of infective complications following penetrating abdominal trauma is controversial, however, as no randomised placebo controlled trials have been published to date. There has also been debate about the timing of antibiotic prophylaxis. In 1972 Fullen noted a 7% to 11% post-surgical infection rate with pre-operative antibiotics, a 33% to 57% infection rate with intra-operative antibiotic administration and 30% to 70% infection rate with only post-operative antibiotic administration. Current guidelines state there is sufficient class I evidence to support the use of a single pre-operative broad spectrum antibiotic dose, with aerobic and anaerobic cover, and continuation (up to 24 hours) only in the event of a hollow viscus perforation found at exploratory laparotomy. To assess the benefits and harms of prophylactic antibiotics administered for penetrating abdominal injuries for the reduction of the incidence of septic complications, such as septicaemia, intra-abdominal abscesses and wound infections. Searches were not restricted by date, language or publication status. We searched the following electronic databases: the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2013, issue 12 of 12), MEDLINE (OvidSP), Embase (OvidSP), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S) and PubMed. Searches were last conducted in January 2013. All randomised controlled trials of antibiotic prophylaxis in patients with penetrating abdominal trauma versus no
Held, M; Engelmann, E; Dunn, R; Ahmad, S S; Laubscher, M; Keel, M J B; Maqungo, S; Hoppe, S
A growing burden of gunshot injuries demands evidence-based ballistic trauma management. No comprehensive systematic overview of the current knowledge is available to date. This study aims to identify and analyze the most influential publications in the field of orthopedic ballistic trauma research. All databases available in the Thomson Reuters Web of Knowledge were searched to conduct this bibliometrical study. The most cited orthopedic ballistic trauma articles published between 1950 and 2015 were identified by use of a multi-step approach. Publications with ten citations and more were analyzed for citations, journal, authorship, geographic origin, area of research, anatomical site, study type, study category, and level of evidence. Citations of the 128 included studies ranged from 113 to 10. These were published in fifty different journals between 1953 and 2011. Most publications (n=106; 83%) originated from the USA, were retrospective (n=85; 66.4%), level IV studies (n=90; 70.3%), reported on spinal gunshot injuries (n=49; 38.33%) and were published between 1980 and 2000 (n=111; 86.7%). This bibliometric study provides the first comprehensive overview of influential publications in the field of orthopedic ballistic trauma research. More prospective studies and high-quality systematic reviews are needed. Centres with a high burden of gunshot injuries from the developing world need to share their experience in form of international publications, to provide a more comprehensive picture of the global gun-related orthopedic injury burden. bibliometric analysis: level III. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Bodalal, Zuhir; Mansor, Salah
Since independence, Libya has never experienced personal ownership of arms. That changed during the Libyan conflict where weapons became widespread in the society. As a result gunshot injuries became a concern for surgeons at our principal surgical hospital (Al-Jalaa). This study aims at analyzing the gunshot injuries that took place during 2011 and highlighting the peculiarities in the Libyan scenario. Patient records were obtained and gunshot injuries were analyzed for various parameters. Statistical analyses were made taking into consideration situations faced by neighbouring countries. In 2011, 1761 patients were admitted with over 95% being male and over 97% were Libyan. The average age of a GSI patient was 28.32 ± 10.01 years. Patients aged 18-35 formed over 70% of the cases with half of all cases being treated by the orthopedics department. Sixty-eight percent of cases were injured in the extremities followed by chest (12.5%) and abdomen injuries (7.8%). The mortality rate for GSI's was found to be 5.6% overall with young age, site of injury (i.e. chest and head) and cause of injury (i.e. war or civilian fighting) being important risk factors. Taking into consideration the difficult operating conditions and limited resources, surgeons at our hospital were able to maintain a low mortality rate. Disarmament needs to begin as soon as possible because these injuries will continue to occur so long firearms are available in society. Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Accurate and considered wound assessment is essential to fulfil professional nursing requirements and ensure appropriate patient and wound management. This article describes the main aspects of holistic assessment of the patient and the wound, including identifying patient risk factors and comorbidities, and factors affecting wound healing to ensure optimal outcomes.
Green, Ben; Horel, Thibaut; Papachristos, Andrew V
Every day in the United States, more than 200 people are murdered or assaulted with a firearm. Little research has considered the role of interpersonal ties in the pathways through which gun violence spreads. To evaluate the extent to which the people who will become subjects of gun violence can be predicted by modeling gun violence as an epidemic that is transmitted between individuals through social interactions. This study was an epidemiological analysis of a social network of individuals who were arrested during an 8-year period in Chicago, Illinois, with connections between people who were arrested together for the same offense. Modeling of the spread of gunshot violence over the network was assessed using a probabilistic contagion model that assumed individuals were subject to risks associated with being arrested together, in addition to demographic factors, such as age, sex, and neighborhood residence. Participants represented a network of 138 163 individuals who were arrested between January 1, 2006, and March 31, 2014 (29.9% of all individuals arrested in Chicago during this period), 9773 of whom were subjects of gun violence. Individuals were on average 27 years old at the midpoint of the study, predominantly male (82.0%) and black (75.6%), and often members of a gang (26.2%). Explanation and prediction of becoming a subject of gun violence (fatal or nonfatal) using epidemic models based on person-to-person transmission through a social network. Social contagion accounted for 63.1% of the 11 123 gunshot violence episodes; subjects of gun violence were shot on average 125 days after their infector (the person most responsible for exposing the subject to gunshot violence). Some subjects of gun violence were shot more than once. Models based on both social contagion and demographics performed best; when determining the 1.0% of people (n = 1382) considered at highest risk to be shot each day, the combined model identified 728 subjects of gun violence
Zeichner, A; Levin, N; Dvorachek, M
Ammunition having mercury fulminate-based primers are commonly manufactured by Eastern Bloc countries and used extensively in the Middle East. Gunshot residue (GSR) particles formed by firing these types of ammunition were examined. It was observed that much lower percentage of mercury-containing GSR particles were found in samples taken from a shooter as compared to the percentage of such particles in samples from cartridge cases. This fact must therefore be taken into account when interpreting case results. A plausible explanation for the results described is proposed.
Leppäniemi, Ari; Haapiainen, Reijo
Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent
... flap is necessary, the surgeon may take a piece of muscle from your buttocks, shoulder, or upper chest to put over your wound. If you need this, the surgeon will not do this until after the infection has cleared.
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Eardley, W. G. P.; Brown, K. V.; Bonner, T. J.; Green, A. D.; Clasper, J. C.
Although mechanisms of modern military wounding may be distinct from those of ancient conflicts, the infectious sequelae of ballistic trauma and the evolving microbial flora of war wounds remain a considerable burden on both the injured combatant and their deployed medical systems. Battlefield surgeons of ancient times favoured suppuration in war wounding and as such Galenic encouragement of pus formation would hinder progress in wound care for centuries. Napoleonic surgeons eventually abandoned this mantra, embracing radical surgical intervention, primarily by amputation, to prevent infection. Later, microscopy enabled identification of microorganisms and characterization of wound flora. Concurrent advances in sanitation and evacuation enabled improved outcomes and establishment of modern military medical systems. Advances in medical doctrine and technology afford those injured in current conflicts with increasing survivability through rapid evacuation, sophisticated resuscitation and timely surgical intervention. Infectious complications in those that do survive, however, are a major concern. Addressing antibiotic use, nosocomial transmission and infectious sequelae are a current clinical management and research priority and will remain so in an era characterized by a massive burden of combat extremity injury. This paper provides a review of infection in combat wounding from a historical setting through to the modern evidence base. PMID:21149356
Stojadinovic, Alexander; Elster, Eric; Potter, Benjamin K; Davis, Thomas A; Tadaki, Doug K; Brown, Trevor S; Ahlers, Stephen; Attinger, Christopher E; Andersen, Romney C; Burris, David; Centeno, Jose; Champion, Hunter; Crumbley, David R; Denobile, John; Duga, Michael; Dunne, James R; Eberhardt, John; Ennis, William J; Forsberg, Jonathan A; Hawksworth, Jason; Helling, Thomas S; Lazarus, Gerald S; Milner, Stephen M; Mullick, Florabel G; Owner, Christopher R; Pasquina, Paul F; Patel, Chirag R; Peoples, George E; Nissan, Aviram; Ring, Michael; Sandberg, Glenn D; Schaden, Wolfgang; Schultz, Gregory S; Scofield, Tom; Shawen, Scott B; Sheppard, Forest R; Stannard, James P; Weina, Peter J; Zenilman, Jonathan M
The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms, and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care.
Coca Robinot, D; Liébana de Rojas, C; Aguirre Pascual, E
Abdominal symptoms are among the most common reasons for pediatric emergency department visits, and abdominal pain is the most frequently reported symptom. Thorough history taking and physical examination can often reach the correct diagnosis. Knowing the abdominal conditions that are most common in each age group can help radiologists narrow the differential diagnosis. When imaging tests are indicated, ultrasonography is usually the first-line technique, enabling the diagnosis or adding relevant information with the well-known advantages of this technique. Nowadays, plain-film X-ray studies are reserved for cases in which perforation, bowel obstruction, or foreign body ingestion is suspected. It is also important to remember that abdominal pain can also occur secondary to basal pneumonia. CT is reserved for specific indications and in individual cases, for example, in patients with high clinical suspicion of abdominal disease and inconclusive findings at ultrasonography. We review some of the most common conditions in pediatric emergencies, the different imaging tests indicated in each case, and the imaging signs in each condition. Copyright © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved.
Gerlach, Undine A; Pascher, Andreas
Abdominal wall closure after intestinal transplantation (ITX) or multivisceral transplantation (MVTX) is challenging because of the loss of abdominal domain and wall elasticity as a result of previous operations and donor-to-recipient weight and height mismatch. We report on abdominal wall closure management in 30 ITX and MVTX recipients. In 60% of patients (n = 18), a primary abdominal closure (PAC) was achieved, in 40% (n = 12) a staged closure (SAC) was necessary. Patients with PAC had undergone less pretransplant operations and required less posttransplant relaparotomies. They were mainly ITX recipients or more abdominal domain because of a longer intestinal remnant. A literature review revealed different strategies to overcome a failed primary closure. They focus on graft reduction or an enlargement of the abdominal domain. The latter includes temporary coverage with prosthetic materials for SAC. Definite abdominal closure is achieved by skin only closure, or by using acellular dermal matrix, rotational flaps, rectus muscle fascia or abdominal wall grafts. Abdominal wall reconstruction after ITX/MVTX is commonly demanded and can be conducted by different strategies. The technique should be easy to use in a timely manner and should prevent abdominal infections, intestinal fistulation, incisional hernias, and wound dehiscence.
Erol, Özge Ö; Erdoğan, Behice Y; Onar, Atiye N
Simultaneous determination of nitrate and nitrite in gunshot residue has been conducted by capillary electrophoresis using an acidic run buffer (pH 3.5). In previously developed capillary electrophoretic methods, alkaline pH separation buffers were used where nitrite and nitrate possess similar electrophoretic mobility. In this study, the electroosmotic flow has been reversed by using low pH running buffer without any additives. As a result of reversing the electroosmotic flow, very fast analysis has been actualized, well-defined and separated ion peaks emerge in less than 4 min. Besides, the limit of detection was improved by employing large volume sample stacking. Limit of detection values were 6.7 and 4.3 μM for nitrate and nitrite, respectively. In traditional procedure, mechanical agitation is employed for extraction, while in this work the extraction efficiency of ultrasound mixing for 30 min was found sufficient. The proposed method was successfully applied to authentic gunshot residue samples. © 2016 American Academy of Forensic Sciences.
Hondrogiannis, Ellen; Andersen, Danielle; Miziolek, Andrzej W.
There continues to be a need for improved technology to be used in theater to quickly and accurately identify the person who shot any weapon during a terrorist attack as well as to link a suspect to the actual weapon fired during a crime. Beyond this, in areas of conflict it would be desirable to have the capability to establish the source country for weaponry and ammunition. Gunshot residue (GSR) analysis is a reasonably well-studied technology area. Recent scientific publications have reported that the residues have a rich composition of both organic and inorganic compounds. For the purposes of identifying the manufacturer or country of origin for the ammunition, the inorganic components of GSR appear to be especially promising since their presence in the propellant and primer formulations are either specific to a given chemical formula, or they represent impurities in the manufacturing process that can be unique to a manufacturer or the source country for the chemicals used for propellants and primers. The Laser Induced Breakdown Spectroscopy (LIBS) technology has already demonstrated considerable capability for elemental fingerprinting, especially for inorganic/metallic components. A number of reports have demonstrated LIBS capability in forensics for matching materials such as inks, fabrics, paper, glass, and paint. This work describes the encouraging results of an initial study to assess a new commercial field-portable (battery operated) LIBS system for GSR analysis with gunshot residues having been collected from inside cartridge casings from 3 different ammunition manufacturers.
Steffen, S.; Otto, M.; Niewoehner, L.; Barth, M.; Bro¿żek-Mucha, Z.; Biegstraaten, J.; Horváth, R.
A gunshot residue sample that was collected from an object or a suspected person is automatically searched for gunshot residue relevant particles. Particle data (such as size, morphology, position on the sample for manual relocation, etc.) as well as the corresponding X-ray spectra and images are stored. According to these data, particles are classified by the analysis-software into different groups: 'gunshot residue characteristic', 'consistent with gunshot residue' and environmental particles, respectively. Potential gunshot residue particles are manually checked and - if necessary - confirmed by the operating forensic scientist. As there are continuing developments on the ammunition market worldwide, it becomes more and more difficult to assign a detected particle to a particular ammunition brand. As well, the differentiation towards environmental particles similar to gunshot residue is getting more complex. To keep external conditions unchanged, gunshot residue particles were collected using a specially designed shooting device for the test shots revealing defined shooting distances between the weapon's muzzle and the target. The data obtained as X-ray spectra of a number of particles (3000 per ammunition brand) were reduced by Fast Fourier Transformation and subjected to a chemometric evaluation by means of regularized discriminant analysis. In addition to the scanning electron microscopy in combination with energy dispersive X-ray microanalysis results, isotope ratio measurements based on inductively coupled plasma analysis with mass-spectrometric detection were carried out to provide a supplementary feature for an even lower risk of misclassification.
Mickelson, Megan A; Mans, Christoph; Colopy, Sara A
The care of wounds in exotic animal species can be a challenging endeavor. Special considerations must be made in regard to the animal's temperament and behavior, unique anatomy and small size, and tendency toward secondary stress-related health problems. It is important to assess the entire patient with adequate systemic evaluation and consideration of proper nutrition and husbandry, which could ultimately affect wound healing. This article summarizes the general phases of wound healing, factors that affect healing, and principles of wound management. Emphasis is placed on novel methods of treating wounds and species differences in wound management and healing. Copyright © 2016 Elsevier Inc. All rights reserved.
Bohiltea, R; Radoi, V; Tufan, C; Horhoianu, I A; Bohiltea, C
Abdominal pregnancy, a rare diagnosis, belongs to the ectopic pregnancy group, the leading cause of pregnancy related exitus. The positive diagnosis is very difficult to establish most often in an acute setting, leading to a staggering percent of feto-maternal morbidity and mortality. We present the case of 26-weeks-old abdominal pregnancy with partial feto-placental detachment in a patient, after hysteroscopy and in vitro fertilization, which until the acute symptoms that led to emergency laparotomy went unrecognized. The patient recovered completely and satisfactorily after surgery and, due to the high risk of uterine rupture with regard to a second pregnancy, opted for a surrogate mother. Abdominal pregnancy can be regarded as a difficult to establish diagnosis, with a greater chance in case of increased awareness. It is compulsory to be well informed in order not to be surprised by the diagnosis and to apply the correct treatment immediately as the morbidity and mortality rate is elevated.
O'Brien, Melissa L; Lawton, Joanna E; Conn, Chris R; Ganley, Helen E
This article describes the barriers, changes and achievements related to implementing one element of a wound care programme being best practice care. With the absence of a coordinated approach to wound care, clinical practice within our Area Health Service (AHS) was diverse, inconsistent and sometimes outdated. This was costly and harmful, leading to overuse of unhelpful care, underuse of effective care and errors in execution. The major aim was to improve the outcomes and quality of life for patients with wound care problems within our community. A collaborative across ten sites/services developed, implemented and evaluated policies and guidelines based on evidence-based bundles of care. Key barriers were local resistance and lack of experience in implementing structural and cultural changes. This was addressed by appointing a wound care programme manager, commissioning of a strategic oversight committee and local wound care committees. The techniques of spread and adoption were used, with early adopters making changes observable and allowing local adaption of guidelines, where appropriate. Deployment and improvement results varied across the sites, ranging from activity but no changes in practice to modest improvement in practice. Evaluating implementation of the leg ulcer guideline as an exemplar, it was demonstrated that there was a statistically significant improvement in overall compliance from 26% to 84%. However, only 7·7% of patients received all interventions to which they were entitled. Compliance with the eight individual interventions of the bundle ranged from 26% to 84%. Generic performance was evaluated against the wound assessment, treatment and evaluation plan with an average compliance of 70%. Early results identified that 20% of wounds were healed within the target of 10 days. As more standardised process are implemented, clinical outcomes should continue to improve and costs decrease. © 2011 The Authors. © 2011 Blackwell Publishing Ltd and
Lee, Ser Yee; Pormento, James G; Koong, Heng Nung
Abdominal paracentesis and thoracocentesis are common bedside procedures with diagnostic, therapeutic and palliative roles. We describe a useful and familiar a useful and familiar technique with the use of a multiple lumen catheter commonly used for central venous line insertion for drainage of ascites or moderate to large pleural effusions. The use of a multiple lumen catheter allows easier and more rapid aspiration of fluid with a smaller probability of the side holes being blocked as compared to the standard needle or single catheter methods. This is particularly useful in situations where the dedicated commercial kits for thoracocentesis and abdominal paracentesis are not readily available.
Kohlberg, W I; Tellis, V A; Bhat, D J; Driscoll, B; Veith, F J
Wound infections after transplant nephrectomy were analyzed retrospectively. When prophylactic antibiotics were not used, 20% of the closed nephrectomy wounds became infected. Eighty-one percent of the infections were due to staphylococcal organisms. Wounds containing a preexisting focus of infection or those reoperated on more than once within a month prior to nephrectomy are at such high risk for infection that these wounds should be left open for secondary healing. With the use of prophylactic cefazolin sodium, in the immediate preoperative and postoperative period, no wound infections have occurred in 18 closed transplant nephrectomy wounds.
To review the current developments in staged abdominal re-operation for abdominal trauma. To overview the steps of damage control laparotomy. The ever increasing importance of the resuscitation phase with current intensive care unit (ICU) support techniques should be emphasized. General surgeons should be familiar to staged abdominal re-operation for abdominal trauma and collaborate with ICU teams, interventional radiologists and several other specialties to overcome this entity.
for selective nonoperative management (SNOM) for abdominal trauma to minimize morbidity from nontherapeutic laparotomies (NTLs); however, this treatment...credited for introducing selective nonoperative management (SNOM) for penetrating abdominal trauma.2 SNOM, which now encompasses both penetrating and...BAT), 30% of anterior and 67% of back abdominal gunshot wounds, as well as 50% of anterior and 85% of back stab wounds can be managed using SNOM
The development of molecular biology and other new biotechnologies helps us to recognize the wound healing and non-healing wound of skin in the past 30 years. This review mainly focuses on the molecular biology of many cytokines (including growth factors) and other molecular factors such as extracellular matrix (ECM) on wound healing. The molecular biology in cell movement such as epidermal cells in wound healing was also discussed. Moreover many common chronic wounds such as pressure ulcers, leg ulcers, diabetic foot wounds, venous stasis ulcers, etc. usually deteriorate into non-healing wounds. Therefore the molecular biology such as advanced glycation end products (AGEs) and other molecular factors in diabetes non-healing wounds were also reviewed. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.
Grover, Madhusudan; Drossman, Douglas A
Functional abdominal pain syndrome (FAPS) is a relatively less common functional gastrointestinal (GI) disorder defined by the presence of constant or frequently recurring abdominal pain that is not associated with eating, change in bowel habits, or menstrual periods (Drossman Gastroenterology 130:1377-1390, 2006), which points to a more centrally targeted (spinal and supraspinal) basis for the symptoms. However, FAPS is frequently confused with irritable bowel syndrome and other functional GI disorders in which abdominal pain is associated with eating and bowel movements. FAPS also differs from chronic abdominal pain associated with entities such as chronic pancreatitis or chronic inflammatory bowel disease, in which the pain is associated with peripherally acting factors (eg, gut inflammation or injury). Given the central contribution to the pain experience, concomitant psychosocial disturbances are common and strongly influence the clinical expression of FAPS, which also by definition is associated with loss of daily functioning. These factors make it critical to use a biopsychosocial construct to understand and manage FAPS, because gut-directed treatments are usually not successful in managing this condition.
Nemeth, A J
The advances in laser surgery over the past decade have been remarkable and have significantly altered the management of a host of dermatologic disorders. This article focuses on the CO2 laser as a cutting and vaporization tool and reviews the features that distinguish CO2 laser-induced wounds from those created by a scalpel. Tissue welding, wound management after skin treatment with the visible light lasers based on the principle of selective photothermolysis, as well as the controversial field of low-energy laser therapy (biostimulation) are also addressed.
Morton, Laurel M; Phillips, Tania J
Wounds are an excellent example of how the field of dermatology represents a cross-section of many medical disciplines. For instance, wounds may be caused by trauma, vascular insufficiency, and underlying medical conditions, such as diabetes, hypertension, and rheumatologic and inflammatory disease. This continuing medical education article provides an overview of wound healing and the pathophysiology of chronic wounds and reviews the broad differential diagnosis of chronic wounds. It also describes the initial steps necessary in evaluating a chronic wound and determining its underlying etiology. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
Inoue, Yuji; Hasegawa, Minoru; Maekawa, Takeo; Le Pavoux, Andres; Asano, Yoshihide; Abe, Masatoshi; Ishii, Takayuki; Ito, Takaaki; Isei, Taiki; Imafuku, Shinichi; Irisawa, Ryokichi; Ohtsuka, Masaki; Ohtsuka, Mikio; Ogawa, Fumihide; Kadono, Takafumi; Kodera, Masanari; Kawakami, Tamihiro; Kawaguchi, Masakazu; Kukino, Ryuichi; Kono, Takeshi; Sakai, Keisuke; Takahara, Masakazu; Tanioka, Miki; Nakanishi, Takeshi; Nakamura, Yasuhiro; Hashimoto, Akira; Hayashi, Masahiro; Fujimoto, Manabu; Fujiwara, Hiroshi; Matsuo, Koma; Madokoro, Naoki; Yamasaki, Osamu; Yoshino, Yuichiro; Tachibana, Takao; Ihn, Hironobu
The Japanese Dermatological Association determined to prepare the Wound/Burn Guidelines focusing on treatments, catering to needs for the clinical practice of dermatology. Among these guidelines, "Wounds in General" was intended to explain knowledge necessary "to heal wounds" without specifying particular disorders. © 2016 Japanese Dermatological Association.
Barhoum, Masad; Tobias, Samuel; Elron, Moshe; Sharon, Aviram; Heija, Tariq; Soustiel, Jean F
As an expected consequence of the civil war in Syria, emergent neurosurgical care for battlefield trauma has been provided for severely head-injured Syrians transferred to Northern Israel. Sixty-six patients suffering from brain injury were brought to the border and then referred to the institution after initial resuscitation. Both the time and type of injury were recorded based on paramedic testimony, forensic material or on details provided by patients. A retrospective analysis of all medical charts and imaging material was performed. Most injuries were combat-related, either caused by blast (13.6%), shrapnel (24.2%), assault (28.8%) or gunshot wound (15.2%). Only a minority of patients (18.2%) suffered from injuries that were not directly caused by weapon. A total of 55 surgical procedures were performed in 46 out of 66 patients, including craniotomies in 40 patients, burr hole alone for placement of intraparenchymal intracranial pressure (ICP) sensor in nine instances and ventricle peritoneal shunt in two patients. Decompressive craniectomy was used only for the treatment of gunshot wound and was performed in eight out of 10 patients. The most common complication consisted in cerebrospinal fluid fistulas (16.7%). Post-operative infections occurred in seven patients (10.6%). Short-term outcomes were favourable in 60.7%, with a mortality rate of 4.5%. The present findings suggest that aggressive surgery and neuro-intensive care measures may lead to good functional results, even in the presence of seemingly devastating injuries in some selected patients.
Nikolaos, Tsiatis E.
An experiment was conducted in an open practice ground (shooting range) regarding the recording of the sound of gunshots. Shots were fired using various types of firearms (seven pistols, five revolvers, two submachine guns, one rifle, and one shotgun) in different calibers, from several various distances with reference to the recording sources. Both, a conventional sound level meter (device) and a measurement microphone were used, having been placed in a fixed point behind the shooting line. The sound of each shot was recorded (from the device). At the same time the signal received by the microphone was transferred to a connected computer through an appropriate audio interface with a pre-amplifier. Each sound wave was stored and depicted as a wave function. After the physic-mathematical analysis of these depictions, the volume was calculated in the accepted engineering units(Decibels or dB) of Sound Pressure Level (SPL). The distances from the recording sources were 9.60 meters, 14.40 m, 19.20 m, and 38.40 m. The experiment was carried out by using the following calibers: .22 LR, 6.35 mm(.25 AUTO), 7.62 mm Tokarev(7,62×25), 7.65 mm(.32 AUTO), 9 mm Parabellum(9×19), 9 mm Short(9×17), 9 mm Makarov(9×18), .45 AUTO, .32 S&W, .38 S&W, .38 SPECIAL, .357 Magnum, 7,62 mm Kalashnikov(7,62×39) and 12 GA. Tables are given for the environmental conditions (temperature, humidity, altitude & barometric pressure), the length of the barrel of each gun, technical characteristics of the used ammunition, as well as for the volume taken from the SLM. The data for the sound intensity were collected after 168 gunshots (158 single shot & 10 bursts). According to the results, a decreasing of the volume, equivalent to the increasing of the distance, was remarked, as it was expected. Values seem to follow the Inverse square Law. For every doubling of the distance from the sound source, the sound intensity diminishes by 5.9904±0.2325 decibels (on average). In addition, we have the
Nambiar, Rakul; Anoop, T M; Mony, Rari P
Abdominal wall lesions can be broadly divided into nontumorous and tumorous conditions. Nontumorous lesions include congenital lesion, abdominal wall hernia, inflammation and infection, vascular lesions, and miscellaneous conditions like hematoma. Tumorous lesions include benign and malignant neoplasms. Here, we report an unusual case of abdominal wall endometriosis mimicking metastases in a patient with breast carcinoma.
Arafat, Shawqi; Alsabek, Mhd Belal; Ahmad, Mousa; Hamo, Iman; Munder, Eskander
A large number of innocent Syrians were injured or killed during the years of war. This retrospective study investigates the differences in patterns of injury and factors affecting the mortality rate in 324 patients coming to Damascus Hospital with penetrating abdominal trauma, and illustrates the difficulties of diagnosis and decision making in crisis situations. A retrospective study was registered from patient's records between October 2012 and June 2013 in Damascus Hospital. All victims were injured either by explosions or gunshots. A total of 325 patients: 183 by explosion; 56.3%, 141 by gunshot; 43.3%, and one patient by other means; 0.3% were reviewed. The study focused on the two large groups with a total of 324 patients. Males were predominant (82.1%; n=266) and the majority of patients were between 19 and 35 years old. Patients suffering from multi abdominal organ injury were more common in gunshot group (n=72, 51.1%) compared to the explosion group (n=83, 45.3%). 264 patients (81.5%) underwent surgical operations and only 22 (8.3%) had normal laparotomy. The inpatient mortality rate was (17.0%; n=55), and there was no difference in mortality rate between the two groups. More than the half of deaths (n=42; 76.4%) had a P.A.T.I score≥25 where the death rate was 35.6% which is higher compared to 6.3% in those with a P.A.T.I<25. In the ICU 33 patients died, of these (87.9%; n=29) died after immediate admission to the ICU which is higher compared with a later admission (12.1%; n=4). The need for massive blood transfusion affected the mortality rate. Efforts must be directed toward training of medical staff to deal with crisis incidents. The need for massive blood transfusion and ICU admissions can affects mortality. P.A.T.I was found to be an effective predictor of mortality. Clinical experience in this field can produce better health care and faster judgments. Copyright © 2017 Elsevier Ltd. All rights reserved.
Naidoo, Natasha; Muckart, David J J
Injury in childhood is a major cause of potentially preventable morbidity and mortality. In order to implement effective preventive strategies, epidemiological data on mechanisms of injury and outcome are essential. To assess the causation, severity of injury, morbidity and mortality of paediatric trauma admitted to a level 1 trauma intensive care unit (TICU). Children were defined as being <16 years of age. The study covered the 5-year period January 2008-December 2012. Eligible patients were identified from a prospective database maintained in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Data extracted were referral source, mechanism of injury, age and gender distribution, injury severity score (ISS), anatomical distribution of injury and mortality. A total of 181 patients admitted during the study period accounted for 15.9% of all admissions. There were 84 females (46.4%) and 97 males (53.6%), with a median age of 7 years (interquartile range (IQR) 4-10). Sources of admission were directly from the scene in 38 cases (21.0%), from a primary healthcare facility in 47 (26.0%), from a regional hospital in 56 (31.0%) and from a tertiary facility in 40 (22.0%). Mortality rates according to location of transfer were regional hospital 8 deaths (30.8%), tertiary facility 7 (26.9%), primary health clinic 7 (26.9%), and from the scene 4 (15.4%). Mechanisms of injury were pedestrian-motor vehicle collision (PMVC) in 105 cases (58.0%), motor vehicle passenger in 38 (21.0%), non-vehicular blunt trauma in 18 (10.0%), gunshot wounds (GSWs) in 12 (6.6%), stab wounds in 6 (3.3%), bull goring in 1 (0.5%) and bicycle accident 1 (0.5%). The median ISS for all admissions was 25 (IQR 16-38). ISSs were >25 in 98 patients (54.1%), 16-25 in 51 (28.2%), 9-15 in 9 (4.9%) and <9 in 13 (7.2%); 61.9% of patients had head injuries, 48.1% injuries to the extremities, 41.4% abdominal trauma, 40.3% thoracic trauma, 20.4% external soft-tissue trauma, 9
Devriendt, Nausikaa; de Rooster, Hilde
When traumatic wounds are quickly and accurately treated, morbidity and costs can be significantly decreased. Several factors, such as time delay between injury and treatment, the degree of contamination, extension and depth of the wound, and the mechanism of injury, influence the treatment and prognosis and stress the importance of a patient-specific approach. Although all traumatic wounds are contaminated, antibiotic therapy is seldom required if correct wound management is installed. Copyright © 2017 Elsevier Inc. All rights reserved.
Yılmaz, Kerim Bora; Akıncı, Melih; Doğan, Lütfi; Karaman, Niyazi; Özaslan, Cihangir; Atalay, Can
Post-laparotomy wound dehiscence, evantration and evisceration are important complications leading to an increase in both morbidity and mortality. Incisional hernias are frequently observed following abdominal surgeries and their occurrence is related to various local and systemic factors. This study aims to analyze the factors affecting wound healing by investigating the parameters that may cause wound dehiscence, incisional hernia, sinus formation and chronic incisional pain. The records of 265 patients who underwent major abdominal surgery were analyzed. The data on patient characteristics, medication, surgical procedure type, type of suture and surgical instruments used and complications were recorded. The patients were followed up with respect to sinus formation, incisional hernia occurrence and presence of chronic incision pain. Statistical analysis was performed using SPSS 10.00 program. The groups were compared via chi-square tests. Significance was determined as p<0.05. Multi-variate analysis was done by forward logistic regression analysis. 115 (43.4%) patients were female and 150 (56.6%) were male. Ninety-four (35.5%) patients were under 50 years old and 171 (64.5%) were older than 50 years. The median follow-up period was 28 months (0-48). Factors affecting wound dehiscence were found to be; creation of an ostomy (p=0.002), postoperative pulmonary problems (p=0.001) and wound infection (p=0.001). Factors leading to incisional hernia were; incision type (p=0.002), formation of an ostomy (p=0.002), postoperative bowel obstruction (p=0.027), postoperative pulmonary problems (p=0.017) and wound infection (p=0.011). Awareness of the factors causing wound dehiscence and incisional hernia in abdominal surgery, means of intervention to the risk factors and taking relevant measures may prevent complications. Surgical complications that occur in the postoperative period are especially related to wound healing problems.
Carballeira Álvarez, A; Mancini, J; Tuchtan-Torrents, L; Gach, P; Bartoli, C; Desfeux, J; Piercecchi, M D; Gorincour, G
To determine the diagnostic capabilities of unenhanced postmortem computed tomography (UPMCT) in detecting traumatic abdominal injuries. Cases of traumatic death with both UPMCT and classical autopsy were collected retrospectively from our institution "virtopsy" database in a period of 5 years. Cadavers with gunshot injuries were excluded. Sensitivity, specificity, accuracy, negative (NPV) and positive (PPV) predictive values of PMCT globally and for hemoperitoneum, liver, spleen, pancreas and kidney injuries individually were estimated using the autopsy report as gold standard. Seventy-one cadavers were included. UPMCT had a sensitivity of 80% and a specificity 94%, with an accuracy of 83%, a PPV of 98% and a NPV of 59% for the diagnosis of traumatic abdominal injuries. The highest sensitivity was obtained for the detection of hepatic injuries (71%) and the lowest for pancreatic injuries (12%). UPMCT had a specificity of 100% for the detection of hemoperitoneum. A NPV of 98% was found for the detection of perihepatic hematomas. The low sensitivity and low NPV do not support the use of UPMCT as an alternative to conventional autopsy to diagnose and/or rule out traumatic abdominal injuries. Nevertheless, UPMCT remains a helpful tool as it helps detect hemoperitoneum and virtually exclude presence of perihepatic hematomas. Copyright © 2018 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.
Wisted, Eric E.; Lundquist, Susan H.
A cartridge device for removing an analyte from a fluid comprises a hollow core, a sheet composite comprising a particulate-loaded porous membrane and optionally at least one reinforcing spacer sheet, the particulate being capable of binding the analyte, the sheet composite being formed into a spiral configuration about the core, wherein the sheet composite is wound around itself and wherein the windings of sheet composite are of sufficient tightness so that adjacent layers are essentially free of spaces therebetween, two end caps which are disposed over the core and the lateral ends of the spirally wound sheet composite, and means for securing the end caps to the core, the end caps also being secured to the lateral ends of the spirally wound sheet composite. A method for removing an analyte from a fluid comprises the steps of providing a spirally wound element of the invention and passing the fluid containing the analyte through the element essentially normal to a surface of the sheet composite so as to bind the analyte to the particulate of the particulate-loaded porous membrane, the method optionally including the step of eluting the bound analyte from the sheet composite.
Ovchinnikov, Iu V; Kharitonov, M A; Sadykov, R R; Shelukhin, V A; Gaĭduk, S V; Bogomolov, A B; Ivanov, V V; Dobrovol'skaia, L M
Pneumonia is one of the common complications of wounds of any localization. Therapists are involved into the treatment of lung lesions in wounded in the ICU, in the surgical and if the patient arrives "on follow-up care,"--in the medical ward. The article analyzes the main statistical indicators reflecting the prevalence and clinical and pathogenetic characteristics of lung pathology in wounded during the Great Patriotic War, during the fighting Soviet troops in the Republic of Afghanistan, the 1st and 2nd Chechen campaign. Pneumonia as a manifestation of traumatic disease can occur in two ways. Primary pneumonia is in close connection with the pathogenetic traumatic injury. Secondary lung lesions complicate the injury at a later date and are due to the introduction of a nosocomial infection process flora. We describe the clinical picture of pneumonia in the affected, the basic pathogenesis, principles of therapy. Successful treatment of lung pathology in wounded depends on the performance of a complex of activities involving a wide range of doctors of various specialties.
Wisted, E.E.; Lundquist, S.H.
A cartridge device for removing an analyte from a fluid comprises a hollow core, a sheet composite comprising a particulate-loaded porous membrane and optionally at least one reinforcing spacer sheet, the particulate being capable of binding the analyte, the sheet composite being formed into a spiral configuration about the core, wherein the sheet composite is wound around itself and wherein the windings of sheet composite are of sufficient tightness so that adjacent layers are essentially free of spaces therebetween, two end caps which are disposed over the core and the lateral ends of the spirally wound sheet composite, and means for securing the end caps to the core, the end caps also being secured to the lateral ends of the spirally wound sheet composite. A method for removing an analyte from a fluid comprises the steps of providing a spirally wound element of the invention and passing the fluid containing the analyte through the element essentially normal to a surface of the sheet composite so as to bind the analyte to the particulate of the particulate-loaded porous membrane, the method optionally including the step of eluting the bound analyte from the sheet composite. 4 figs.
... weapons, and more. In the U.S., millions of people injure themselves every year. These injuries range from minor to life-threatening. Injuries can happen at work or play, indoors or outdoors, driving a car, or walking across the street. Wounds are injuries that break the skin or ...
Church, Deirdre; Elsayed, Sameer; Reid, Owen; Winston, Brent; Lindsay, Robert
Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices. PMID:16614255
Adams, Erica J.
As many as 9 in 10 justice-involved youth are affected by traumatic childhood experiences. According to "Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense," between 75 and 93 percent of youth currently incarcerated in the justice system have had at least one traumatic experience, including sexual…
A study of 104 gunshot suicides, including six women, in Northern Ireland over a 5-year period. Forty-five suicides in the security forces are compared with 59 which took place in the civilian population. The former were commonly associated with marital problems and overwhelmingly occurred in young males under the age of 40, whereas the civilian deaths were predominantly associated with mental ill health, with a wider age range distribution. The security forces used rifled weapons in 44 cases, whereas civilians used shotguns in 46 cases. Twelve out of the 45 were witnessed, compared to one in the civilian population. The security forces favoured the head as site of entry in 40 cases compared to 35 in the civilian population. Alcohol consumption was involved in 23 of the security forces suicides and 18 civilian. Of the 6 women, one was in the security forces and 4 had a history of mental illness.
Nawal, Ruchika Roongta; Sehgal, Ritu; Ansari, Irfan; Talwar, Sangeeta; Sood, Abhinav; Verma, Mahesh
A 37-year-old man reported to our department with the history of gunshot injury to the mandible 15 years before. His anterior mandible had been resected earlier and bone graft was seen. Intraoral examination of lower jaw revealed 4 remaining mandibular molars. These teeth were severely rotated such that they lay horizontal with respect to the mandibular base. Preoperative Dentascan spiral computerized tomography (CT) of the patient revealed obliteration of the mesial canals of the mandibular right first molar and pear-shaped internal resorption defect in the distal canal of the same tooth. This paper reports the challenging endodontic management of a rare case of severely angulated teeth also exhibiting traumatic sequelae in both roots of the impact tooth. It also highlights the usefulness of spiral CT scan in diagnosis of traumatic sequelae such as pulp canal obliteration and internal resorption.
Dabiri, Ganary; Damstetter, Elizabeth; Phillips, Tania
Significance: Chronic wounds are a major healthcare burden.The practitioner should have an appropriate understanding of both the etiology of the wound as well as the optimal type of dressings to use. Fundamental wound characteristics may be used to guide the practitioner's choice of dressings. The identification of optimal dressings to use for a particular wound type is an important element in facilitating wound healing. Recent Advances: Researchers have sought to design wound dressings that aim to optimize each stage in the healing process. In addition, dressings have been designed to target and kill infection-causing bacteria, with the incorporation of antimicrobial agents. Critical Issues: Chronic wounds are frequently dynamic in presentation, and the numerous wound dressings available make dressing selection challenging for the practitioner. Choosing the correct dressing decreases time to healing, provides cost-effective care, and improves patient quality of life. Future Directions: Research into the mechanisms of wound healing has enhanced our ability to heal chronic wounds at a faster rate through the use of moisture-retentive dressings. Newer dressings are incorporating the use of nanotechnology by incorporating miniature electrical sensors into the dressing. These dressings are engineered to detect changes in a wound environment and alert the patient or practitioner by altering the color of the dressing or sending a message to a smartphone. Additional investigations are underway that incorporate biologic material such as stem cells into dressings. PMID:26858913
Schauer, Steven G; April, Michael D; Naylor, Jason F; Simon, Erica M; Fisher, Andrew D; Cunningham, Cord W; Morissette, Daniel M; Fernandez, Jessie Renee D; Ryan, Kathy L
Thoracic trauma represents 5% of all battlefield injuries. Communicating pneumothoraces resulting in tension physiology remain an important etiology of prehospital mortality. In addressing penetrating chest trauma, current Tactical Combat Casualty Care (TCCC) guidelines advocate the immediate placement of a vented chest seal device. Although the Committee on TCCC (CoTCCC) has approved numerous chest seal devices for battlefield use, few data exist regarding their use in a combat zone setting. To evaluate adherence to TCCC guidelines for chest seal placement among personnel deployed to Afghanistan. We obtained data from the Prehospital Trauma Registry (PHTR). Joint Trauma System personnel linked patients to the Department of Defense Trauma Registry, when available, for outcome data upon reaching a fixed facility. In the PHTR, we identified 62 patients with documented gunshot wound (GSW) or puncture wound trauma to the chest. The majority (74.2%; n = 46) of these were due to GSW, with the remainder either explosive-based puncture wounds (22.6%; n = 14) or a combination of GSW and explosive (3.2%; n = 2). Of the 62 casualties with documented GSW or puncture wounds, 46 (74.2%) underwent chest seal placement. Higher proportions of patients with medical officers in their chain of care underwent chest seal placement than those that did not (63.0% versus 37.0%). The majority of chest seals placed were not vented. Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines, despite the guideline update midway through the study period. These data suggest the need to improve predeployment training on TCCC guidelines and matching of the Army logistical supply chain to the devices recommended by the CoTCCC. 2017.
Schumacher, Rüdiger; Barth, Martin; Neimke, Dieter; Niewöhner, Ludwig
The investigation of gunshot residue (GSR) patterns for shooting range estimation is usually based on visualizing the lead, copper, or nitrocellulose distributions on targets like fabric or adhesive tape by chemographic color tests. The method usually provides good results but has its drawbacks when it comes to the examination of ammunition containing lead-free primers or bloody clothing. A milli-X-ray fluorescence (m-XRF) spectrometer with a large motorized stage can help to circumvent these problems allowing the acquisition of XRF mappings of relatively large areas (up to 20 x 20 cm) in millimeter resolution within reasonable time (2-10 hours) for almost all elements. First experiences in GSR casework at the Forensic Science Institute of the Bundeskriminalamt (BKA) have shown, that m-XRF is a useful supplementation for conventional methods in shooting ranges estimation, which helps if there are problems in transferring a GSR pattern to secondary targets (e.g. bloody or stained garments) or if there is no suitable color test available for the element of interest. The resulting elemental distributions are a good estimate for the shooting range and can be evaluated by calculating radial distributions or integrated count rates of irregular shaped regions like pieces of human skin which are too small to be investigated with a conventional WD-XRF spectrometer. Beside a mapping mode the milli-XRF offers also point and line scan modes which can also be utilized in gunshot crime investigations as a quick survey tool to identify bullet holes based on the elements present in the wipe ring.
Andreotti, Alessandro; Guberti, Vittorio; Nardelli, Riccardo; Pirrello, Simone; Serra, Lorenzo; Volponi, Stefano; Green, Rhys E
In European wetlands, at least 40 bird species are exposed to the risk of lead poisoning caused by ingestion of spent lead gunshot. Adopting a methodology developed in North America, we estimated that about 700,000 individuals of 16 waterbird species die annually in the European Union (EU) (6.1% of the wintering population) and one million in whole Europe (7.0%) due to acute effects of lead poisoning. Furthermore, threefold more birds suffer sub-lethal effects. We assessed the economic loss due to this lead-induced mortality of these 16 species by calculating the costs of replacing lethally poisoned wild birds by releasing captive-bred ones. We assessed the cost of buying captive-bred waterbirds for release from market surveys and calculated how many captive-bred birds would have to be released to compensate for the loss, taking into account the high mortality rate of captive birds (72.7%) in the months following release into the wild. Following this approach, the annual cost of waterbird mortality induced by lead shot ingestion is estimated at 105 million euros per year in the EU countries and 142 million euros in the whole of Europe. An alternative method, based upon lost opportunities for hunting caused by deaths due to lead poisoning, gave similar results of 129 million euros per year in the EU countries and 185 million euros per year in the whole of Europe. For several reasons these figures should be regarded as conservative. Inclusion of deaths of species for which there were insufficient data and delayed deaths caused indirectly by lead poisoning and effects on reproduction would probably increase the estimated losses substantially. Nevertheless, our results suggest that the benefits of a restriction on the use of lead gunshot over wetlands could exceed the cost of adapting to non-lead ammunition. Copyright © 2017 Elsevier B.V. All rights reserved.
Wilson, Michael L; Lewis, Erin R
Firearm trauma is the second most common cause of serious injury among adolescents in the Republic of Djibouti. The aim of this study was to explore the sociodemographic correlates of serious injury and non-fatal gunshot trauma among adolescents in Djibouti. Using multinomial logistic regression, we compared a sample of adolescents (N = 1,711) who self-reported a non-firearm-related serious injury (n = 587) and those who reported a firearm-related injury (n = 101) with non-injured participants (n = 1,023) during a 12-month recall period. Analyses targeted demographic, behavioral, social, mental health, and family factors. After adjusting for covariates, participants reporting a non-firearm-related serious injury were more likely to report having been involved in physical fights (relative risk ratio [RRR] = 145; confidence interval [CI] = [1.04, 2.02), being bullied (RRR = 2.83; CI = [2.24, 3.56]), feeling lonely (RRR = 1.48; CI = [1.11, 1.96]), having signs of depression (RRR = 1.27; CI = [1.02, 1.58]), and be truant from school (RRR = 1.68; CI = [1.25, 2.28]). Those who reported a gunshot injury recorded being bullied (RRR = 2.83; CI = [1.77, 4.53]) and physically attacked at higher rates (RRR = 1.78; CI = [1.09, 2.89]). Serious injuries, whether firearm related or not, are important threats to adolescent health in Djibouti with potentially serious health-related correlates. More research, particularly multilevel designs, are needed to explain context-relevant factors associated with serious trauma in Djibouti.
Bouyou, J; Gaujoux, S; Marcellin, L; Leconte, M; Goffinet, F; Chapron, C; Dousset, B
Abdominal emergencies during pregnancy (excluding obstetrical emergencies) occur in one out of 500-700 pregnancies and may involve gastrointestinal, gynecologic, urologic, vascular and traumatic etiologies; surgery is necessary in 0.2-2% of cases. Since these emergencies are relatively rare, patients should be referred to specialized centers where surgical, obstetrical and neonatal cares are available, particularly because surgical intervention increases the risk of premature labor. Clinical presentations may be atypical and misleading because of pregnancy-associated anatomical and physiologic alterations, which often result in diagnostic uncertainty and therapeutic delay with increased risks of maternal and infant morbidity. The most common abdominal emergencies are acute appendicitis (best treated by laparoscopic appendectomy), acute calculous cholecystitis (best treated by laparoscopic cholecystectomy from the first trimester through the early part of the third trimester) and intestinal obstruction (where medical treatment is the first-line approach, just as in the non-pregnant patient). Acute pancreatitis is rare, usually resulting from trans-ampullary passage of gallstones; it usually resolves with medical treatment but an elevated risk of recurrent episodes justifies laparoscopic cholecystectomy in the 2nd trimester and endoscopic sphincterotomy in the 3rd trimester. The aim of the present work is to review pregnancy-induced anatomical and physiological modifications, to describe the main abdominal emergencies during pregnancy, their specific features and their diagnostic and therapeutic management. Copyright © 2015. Published by Elsevier Masson SAS.
Gouin, S.; Patel, H.
OBJECTIVE: To review office interventions for minor wounds not requiring sutures, such as abrasions, bites, and lacerations. QUALITY OF EVIDENCE: Most information on minor wound management comes from descriptive studies. Few comparative studies examine the effectiveness of topical antisepsis for minor wounds. Several clinical trials have demonstrated that tissue adhesives produce short- and long-term cosmetic results equivalent to those achieved with suture materials. MAIN MESSAGE: Sterile saline is the least toxic solution for wound irrigation. Chlorhexidine (2%) and povidone iodine (10%) have been the most investigated antiseptic solutions. Systemic antibiotics are unnecessary for wounds unlikely to be infected. All bite wounds require special attention. Primary closure of bite wounds is indicated in certain circumstances: less than 12-hour-old nonpuncture wounds, uninfected wounds, and low-risk lesions (such as on the face). In spite of their many advantages, skin tapes should be used for low-tension wounds only. The popularity of tissue adhesives has greatly increased. Since the advent of newer products (with increased bonding strength and flexibility), adhesives are used to manage most lacerations except those in areas of high tension (e.g., joints) and on mucosal surfaces. CONCLUSION: Minor wounds not requiring sutures can be managed easily in the office. PMID:11340758
Bhandari, Prem Singh; Maurya, Sanjay; Mukherjee, Mrinal Kanti
War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds. PMID:23162233
Moghadamyeghaneh, Zhobin; Hanna, Mark H; Carmichael, Joseph C; Mills, Steven; Pigazzi, Alessio; Nguyen, Ninh T; Stamos, Michael J
Postoperative wound disruption is associated with high morbidity and mortality. We sought to identify the risk factors and outcomes of wound disruption following colorectal resection. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to examine the clinical data of patients who underwent colorectal resection from 2005 to 2013. Multivariate regression analysis was performed to identify risk factors of wound disruption. We sampled a total of 164,297 patients who underwent colorectal resection. Of these, 2073 (1.3 %) had wound disruption. Patients with wound disruption had significantly higher mortality (5.1 vs. 1.9 %, AOR: 1.46, P = 0.01). The highest risk of wound disruption was seen in patients with wound infection (4.8 vs. 0.9 %, AOR: 4.11, P < 0.01). A number of factors are associated with wound disruption such as chronic steroid use (AOR: 1.71, P < 0.01), smoking (AOR: 1.60, P < 0.01), obesity (AOR: 1.57, P < 0.01), operation length more than 3 h (AOR: 1.56, P < 0.01), severe Chronic Obstructive Pulmonary Disease (COPD) (AOR: 1.36, P < 0.01), urgent/emergent admission (AOR: 1.31, P = 0.01), and serum Albumin Level <3 g/dL (AOR: 1.27, P < 0.01). Laparoscopic surgery had significantly lower risk of wound disruption compared to open surgery (AOR: 0.61, P < 0.01). Wound disruption occurs in 1.3 % of colorectal resections, and it correlates with mortality of patients. Wound infection is the strongest predictor of wound disruption. Chronic steroid use, obesity, severe COPD, prolonged operation, non-elective admission, and serum albumin level are strongly associated with wound disruption. Utilization of the laparoscopic approach may decrease the risk of wound disruption when possible.
Bowler, P. G.; Duerden, B. I.; Armstrong, D. G.
The majority of dermal wounds are colonized with aerobic and anaerobic microorganisms that originate predominantly from mucosal surfaces such as those of the oral cavity and gut. The role and significance of microorganisms in wound healing has been debated for many years. While some experts consider the microbial density to be critical in predicting wound healing and infection, others consider the types of microorganisms to be of greater importance. However, these and other factors such as microbial synergy, the host immune response, and the quality of tissue must be considered collectively in assessing the probability of infection. Debate also exists regarding the value of wound sampling, the types of wounds that should be sampled, and the sampling technique required to generate the most meaningful data. In the laboratory, consideration must be given to the relevance of culturing polymicrobial specimens, the value in identifying one or more microorganisms, and the microorganisms that should be assayed for antibiotic susceptibility. Although appropriate systemic antibiotics are essential for the treatment of deteriorating, clinically infected wounds, debate exists regarding the relevance and use of antibiotics (systemic or topical) and antiseptics (topical) in the treatment of nonhealing wounds that have no clinical signs of infection. In providing a detailed analysis of wound microbiology, together with current opinion and controversies regarding wound assessment and treatment, this review has attempted to capture and address microbiological aspects that are critical to the successful management of microorganisms in wounds. PMID:11292638
Sun, Xiaofang; Wu, Shaohan; Xie, Ting; Zhang, Jianping
An open abdomen complicated with small-bowel fistulae becomes a complex wound for local infection, systemic sepsis and persistent soiling irritation by intestinal content. While controlling the fistulae drainage, protecting surrounding skin, healing the wound maybe a challenge. In this paper we described a 68-year-old female was admitted to emergency surgery in general surgery department with severe abdomen pain. Resection part of the injured small bowel, drainage of the intra-abdominal abscess, and fashioning of a colostomy were performed. She failed to improve and ultimately there was tenderness and lot of pus under the skin around the fistulae. The wound started as a 3-cm lesion and progressed to a 6 ×13 (78 cm) around the stoma. In our case we present a novel device for managing colostomy wound combination with negative pressure wound therapy. This tube allows for an effective drainage of small-bowel secretion and a safe build-up of granulation tissue. Also it could be a barrier between the bowel suction point and foam. Management of open abdomen wound involves initial dressing changes, antibiotic use and cutaneous closure. When compared with traditional dressing changes, the NPWT offers several advantages including increased granulation tissue formation, reduction in bacterial colonization, decreased of bowel edema and wound size, and enhanced neovascularization. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
Aspergillus), Blasto- T he use of effective topical chemotherapeutic agents to myces (Candida), and Zygomycetes ( Mucor , Rhizopus).6 reduce...species, 18%; Mucor species and Rhizopus species, acetate in the morning and silver sulfadiazine in the evening. Prophy- 9.1%; and Microspora species and...sensitivity reports, and the patient’s sue, including one patient who required a hip disarticulation response. to control an invasive Mucor burn wound
Chanussot-Deprez, Caroline; Contreras-Ruiz, José
Telemedical wound care is one of the applications of teledermatology. We present our experience using telemedicine in the successful assessment and treatment of three patients with hard-to-heal ulcers. Three patients were seen at the PEMEX General Hospital in Veracruz, Mexico. The first patient was a 53-year-old man with hypertension, morbid obesity, chronic venous insufficiency, recurrent erysipelas, leg ulcers and lymphoedema. There was one ulcer on his left lower leg (20 x 10 cm) and one on his right leg (9 x 7 cm). The second patient was a 73-year-old woman with class III obesity and ulcers in her right leg, secondary to surgical debridement of bullous erysipelas. The third patient was a 51-year-old female with rheumatoid arthritis with one ulcer on each leg and chronic lymphostasis. Photographs with a digital camera were taken and sent weekly via email to a wound care specialist in Mexico City. The photographs allowed the expert to diagnose and evaluate the chronic wounds periodically. In the present cases, telemedicine allowed us to have a rapid evaluation, diagnosis and treatment. The images were of enough quality to be useful and small enough to be sent via regular email to the remote physician who immediately gave his feedback. The expert was confident to give therapeutic recommendations in this way, and we considered this method to be very cost-effective, saving the patient and the health care system, especially in transportation.
Jones, Sophie M; Banwell, Paul E; Shakespeare, Peter G
Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.
Rose, Lloyd F.; Chan, Rodney K.
Significance: While the survival rate of the severely burned patient has improved significantly, relatively little progress has been made in treatment or prevention of burn-induced long-term sequelae, such as contraction and fibrosis. Recent Advances: Our knowledge of the molecular pathways involved in burn wounds has increased dramatically, and technological advances now allow large-scale genomic studies, providing a global view of wound healing processes. Critical Issues: Translating findings from a large number of in vitro and preclinical animal studies into clinical practice represents a gap in our understanding, and the failures of a number of clinical trials suggest that targeting single pathways or cytokines may not be the best approach. Significant opportunities for improvement exist. Future Directions: Study of the underlying molecular influences of burn wound healing progression will undoubtedly continue as an active research focus. Increasing our knowledge of these processes will identify additional therapeutic targets, supporting informed clinical studies that translate into clinical relevance and practice. PMID:26989577
well-known toxicant and the exposure on indoor firing ranges presents a health risk to both range employees and shooters. Contaminated clothing... firing ranges have employed a new control – air shower (AS), although its effectiveness in this particular application has not been examined. The... firing lead- containing ammunition inside a sealed chamber and allowing the gunshot residue to settle on swatches placed inside the chamber. The
Despite the frequency of functional abdominal pain, potentially dangerous causes of abdominal pain need to be excluded. Medical history and clinical examination must focus on red flags and signs for imflammatory or malignant diseases. See the patient twice in the case of severe and acute abdominal pain if lab parameters or radiological examinations are normal. Avoid repeated and useless X-ray exposure whenever possible. In the case of subacute or chronic abdominal pain, lab tests such as fecal calprotectin, helicobacter stool antigen and serological tests for celiac disease are very useful. Elderly patients may show atypical or missing clinical signs. Take care of red herrings and be skeptical whether your initial diagnosis is really correct. Abdominal pain can frequently be an abdominal wall pain.
Lech, Christie; Swaminathan, Anand
This article discusses abdominal aortic emergencies. There is a common thread of risk factors and causes of these diseases, including age, male gender, hypertension, dyslipidemia, and connective tissue disorders. The most common presenting symptom of these disorders is pain, usually in the chest, flank, abdomen, or back. Computed tomography scan is the gold standard for diagnosis of pathologic conditions of the aorta in the hemodynamically stable patient. Treatment consists of a combination of blood pressure and heart rate control and, in many cases, emergent surgical intervention. Copyright © 2017 Elsevier Inc. All rights reserved.
Fernandes, Rigel P.; Ramos, António L. L.; Apolinário, José A.
Shooter localization systems have been subject of a growing attention lately owing to its wide span of possible applications, e.g., civil protection, law enforcement, and support to soldiers in missions where snipers might pose a serious threat. These devices are based on the processing of electromagnetic or acoustic signatures associated with the firing of a gun. This work is concerned with the latter, where the shooter's position can be obtained based on the estimation of the direction-of-arrival (DoA) of the acoustic components of a gunshot signal (muzzle blast and shock wave). A major limitation of current commercially available acoustic sniper localization systems is the impossibility of finding the shooter's position when one of these acoustic signatures is not detected. This is very likely to occur in real-life situations, especially when the microphones are not in the field of view of the shockwave or when the presence of obstacles like buildings can prevent a direct-path to sensors. This work addresses the problem of DoA estimation of the muzzle blast using a planar array of sensors deployed in a drone. Results supported by actual gunshot data from a realistic setup are very promising and pave the way for the development of enhanced sniper localization systems featuring two main advantages over stationary ones: (1) wider surveillance area; and (2) increased likelihood of a direct-path detection of at least one of the gunshot signals, thereby adding robustness and reliability to the system.
Biocina, B; Sutlić, Z; Husedzinović, I; Rudez, I; Ugljen, R; Letica, D; Slobodnjak, Z; Karadza, J; Brida, V; Vladović-Relja, T; Jelić, I
Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature. We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992. There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the
abdominal compartment syndrome, schemic bowel, biliary disease, peptic ulcer disease and astritis requiring laparotomy, small bowel obstruction, rimary fungal...abdominal complications was 25%, with Curl- ng’s ulcer the most common malady (54% of the total), ollowed by esophageal lesions (17%), hemorrhagic...complications in- luded trauma exploratory laparotomy, abdominal com- artment syndrome, ischemic bowel, biliary disease, peptic lcer disease and gastritis, large
Price, Patricia; Fogh, Karsten; Glynn, Chris; Krasner, Diane L; Osterbrink, Jürgen; Sibbald, R Gary
Chronic wound pain is not well understood and the literature is limited. Six of 10 patients venous leg ulcer experience pain with their ulcer, and similar trends are observed for other chronic wounds. Chronic wound pain can lead to depression and the feeling of constant tiredness. Pain related to the wound should be handled as one of the main priorities in chronic wound management together with addressing the cause. Management of pain in chronic wounds depends on proper assessment, reporting and documenting patient experiences of pain. Assessment should be based on six critical dimensions of the pain experience: location, duration, intensity, quality, onset and impact on activities of daily living. Holistic management must be based on a safe and effective mix of psychosocial approaches together with local and systemic pain management. It is no longer acceptable to ignore or inadequately document persistent wound pain and not to develop a treatment and monitoring strategy to improve the lives of persons with chronic wounds. Unless wound pain is optimally managed, patient suffering and costs to health care systems will increase.
van Assen, Tijmen; de Jager-Kievit, Jenneke W A J; Scheltinga, Marc R; Roumen, Rudi M H
The abdominal wall is often neglected as a cause of chronic abdominal pain. The aim of this study was to identify chronic abdominal wall pain syndromes, such as anterior cutaneous nerve entrapment syndrome (ACNES), in a patient population diagnosed with functional abdominal pain, including irritable bowel syndrome, using a validated 18-item questionnaire as an identification tool. In this cross-sectional analysis, 4 Dutch primary care practices employing physicians who were unaware of the existence of ACNES were selected. A total of 535 patients ≥18 years old who were registered with a functional abdominal pain diagnosis were approached when they were symptomatic to complete the questionnaire (maximum 18 points). Responders who scored at least the 10-point cutoff value (sensitivity, 0.94; specificity, 0.92) underwent a diagnostic evaluation to establish their final diagnosis. The main outcome was the presence and prevalence of ACNES in a group of symptomatic patients diagnosed with functional abdominal pain. Of 535 patients, 304 (57%) responded; 167 subjects (31%) recently reporting symptoms completed the questionnaire. Of 23 patients who scored above the 10-point cutoff value, 18 were available for a diagnostic evaluation. In half of these subjects (n = 9) functional abdominal pain (including IBS) was confirmed. However, the other 9 patients were suffering from abdominal wall pain syndrome, 6 of whom were diagnosed with ACNES (3.6% prevalence rate of symptomatic subjects; 95% confidence interval, 1.7-7.6), whereas the remaining 3 harbored a painful lipoma, an abdominal herniation, and a painful scar. A clinically relevant portion of patients previously diagnosed with functional abdominal pain syndrome in a primary care environment suffers from an abdominal wall pain syndrome such as ACNES.
Trinh, Victoria T; Duckworth, Edward A M
Background Abdominal fat grafts are often harvested for use in skull base reconstruction and cerebrospinal fluid (CSF) leak repairs, and for operations traversing the nasal sinuses or mastoid bone. Although the endoscopic transnasal surgery has gained significant popularity, in part because it is considered "scarless," a common adjunct, the abdominal fat graft, can result in a disfiguring scar across the abdomen. Objective This is the first report of a scarless abdominal fat graft technique for skull base reconstruction. Methods Ten patients with a median age of 56.5 years (range: 45-73 years) underwent endoscopic transsphenoidal tumor resection with intraumbilical fat graft harvest. Careful circumferential fat dissection at the umbilicus, with progressive retraction of the graft, was crucial to ensure maximal visualization and to prevent injury to the subcutaneous vessels and rectus fascia. Results Following reconstruction of the sellar skull base, all patients did well postoperatively with no evidence of CSF leak. At 12-week follow-up for all patients, there was no evidence of scar, intracavity hematoma, or wound infection. Conclusions Fat graft harvest through an intraumbilical incision results in a scar-free abdominal harvest, and is a useful procedural adjunct to complement "scarless" brain surgery.
Merli, Daniele; Brandone, Alberto; Amadasi, Alberto; Cattaneo, Cristina; Profumo, Antonella
The identification and quantification of metallic residues produced by gunshots, called gunshot residues (GSR), provide crucial elements in forensic investigations. The research has been largely focused on their collection onto the hands of suspected shooters, but the method is often burdened by risks of contamination. This research was focused on the possibility of sampling GSR trapped inside the nasal mucus of consenting shooters. Samples of the nasal mucus of "blank" control subjects and shooters were chemically analysed by Instrumental Neutron Activation Analysis (INAA), for residues of antimony (Sb) and barium (Ba), while lead (Pb) was excluded as ubiquitously environmental contaminant and due to high instrumental quantification limit (IQL) of INAA for this element. Shots were fired using two types of weapons (pistols and revolvers) and different firing sequences. The mucus was sampled at different times: immediately after the shots, after 30-60-120 and 180 min. Different amounts of Sb and Ba were detected between controls and shooters, witnessing the ability of the nasal mucus to retain GSR at concentrations significantly different even from the highest basal levels. Moreover, in order to simulate actual cases, nasal mucus from five groups of shooters was sampled after different shots with the same weapon and cartridges, immediately and after 1, 3, 12, and 24 h. The highest values were always found in the first 3 h from firing, for both weapons. Interestingly, for all the weapons, significant Sb and Ba concentrations were also found up to 12 h after firing, contrary to what occurs on hands, even though a progressive decrease was detected, with values below the detection threshold only after 24 h, thus demonstrating that GSR are persistent in nasal mucus. These first results proving that both Sb and Ba were qualitatively detectable in the nasal mucus of shooters indicate that the chemical analysis of the nasal mucus of suspected shooters may represent a
Belin, Ronald; Carrington, Scott
Puncture wounds of the foot are a common injury, and infection associated with these injuries may result in considerable morbidity. The pathophysiology and management of a puncture wound is dependent on the material that punctures the foot, the location and depth of the wound, time to presentation, footwear, and underlying health status of the patient. Puncture wounds should not be treated lightly, so accurate diagnosis, assessment, and treatment are paramount. Early incision and drainage, vaccination, and the use of proper antibiotics can lead to positive outcomes and prevent limb-threatening circumstances. Copyright © 2012 Elsevier Inc. All rights reserved.
Molan, Peter; Rhodes, Tanya
Honey has been used as a wound dressing for thousands of years, but only in more recent times has a scientific explanation become available for its effectiveness. It is now realized that honey is a biologic wound dressing with multiple bioactivities that work in concert to expedite the healing process. The physical properties of honey also expedite the healing process: its acidity increases the release of oxygen from hemoglobin thereby making the wound environment less favorable for the activity of destructive proteases, and the high osmolarity of honey draws fluid out of the wound bed to create an outflow of lymph as occurs with negative pressure wound therapy. Honey has a broad-spectrum antibacterial activity, but there is much variation in potency between different honeys. There are 2 types of antibacterial activity. In most honeys the activity is due to hydrogen peroxide, but much of this is inactivated by the enzyme catalase that is present in blood, serum, and wound tissues. In manuka honey, the activity is due to methylglyoxal which is not inactivated. The manuka honey used in wound-care products can withstand dilution with substantial amounts of wound exudate and still maintain enough activity to inhibit the growth of bacteria. There is good evidence for honey also having bioactivities that stimulate the immune response (thus promoting the growth of tissues for wound repair), suppress inflammation, and bring about rapid autolytic debridement. There is clinical evidence for these actions, and research is providing scientific explanations for them.
Freeman, Julie J; Storto, Dominic L P; Berry-Cabán, Cristóbal S
This article describes an unusual case of a vesicocutaneous fistula in a patient with a history of radiation therapy and recent abdominal surgery. A 61-year-old woman was transferred to our acute care facility from a rehabilitation facility, with poor nutritional intake and a concern for urine draining from her wound. A nephrostomy tube was placed (she had only 1 functioning kidney) and negative-pressure wound therapy was used to close the fistula. Urinary diversion via a nephrostomy tube and negative-pressure wound therapy were used to successfully and safely close this vesicocutaneous fistula.
Christey, G R; Poole, G
Reliable and safe access to the abdominal cavity and efficient removal of the resected gallbladder are essential to laparoscopic cholecystectomy. The unpredictable size of the cholecystectomy specimen can sometimes lead to frustration at the time of removal. A simple technique has been developed that allows for tissue extraction and easy fascial closure regardless of the size of the specimen. This is achieved by using a four bite "U-shaped" purse string at the time of Hasson insertion, with cephalad advancement of the proximal two bites. This allows for variable wound extension and secure closure, without the need for additional sutures.
Ecker, Amir L.
What is disclosed is a wound tube heat exchanger in which a plurality of tubes having flattened areas are held contiguous adjacent flattened areas of tubes by a plurality of windings to give a double walled heat exchanger. The plurality of windings serve as a plurality of effective force vectors holding the conduits contiguous heat conducting walls of another conduit and result in highly efficient heat transfer. The resulting heat exchange bundle is economical and can be coiled into the desired shape. Also disclosed are specific embodiments such as the one in which the tubes are expanded against their windings after being coiled to insure highly efficient heat transfer.
Tongyoo, Assanee; Chatthamrak, Putipan; Sriussadaporn, Ekkapak; Limpavitayaporn, Palin; Mingmalairak, Chatchai
The surgical site infection (SSI) is a common complication of abdominal operation. It relates to increased hospital stay, increased healthcare cost, and decreased patient's quality of life. Obesity, usually defined by BMI, is known as one of the risks of SSI. However, the thickness of subcutaneous layers of abdominal wall might be an important local factor affecting the rate of SSI after the abdominal operations. The objective of this study is to assess the importance of the abdominal wall thickness on incisional SSI rate. The subjects of the present study were patients who had undergone major abdominal operations at Thammasat University Hospital between June 2013 and May 2014, and had been investigated with CT scans before their operations. The demographic data and clinical information of these patients were recorded. The thickness ofsubcutaneous fatty tissue from skin down to the most superficial layer of abdominal wall muscle at the surgical site was measured on CT images. The wound infectious complication was reviewed and categorized as superficial and deep incisional SSIfollowing the definition from Centersfor Disease Control and Prevention (CDC) guidelines. The significance ofeach potentialfactors on SSI rates was determined separately with student t-test for quantitative data and χ2-test for categorical data. Then all factors, which had p < 0.10, were included into the multivariate logistic regression analysis and were analyzed with significance at p < 0.05. One hundred and thirty-nine patients were included in this study. They all underwent major abdominal surgery and had had pre-operative CTscans. Post-operative SSI was 25.2% (35/139), superficial and deep types in 27 and 8 patients, respectively. The comparison of abdominal wall thickness between patients with and without infection was significantly different (20.0 ± 8.4 mm and 16.0 ± 7.2 mm, respectively). When the thickness at 20 mm was used as the cut-off value, 43 of 139 patients had abdominal wall
Haycock, Christine E.
In sports, abdominal injuries occur most frequently in cycling, horseback riding, and skiing. Most involve children, not adults. Any athlete sustaining a severe blow to the abdomen should be examined. Guidelines are provided for recognizing and treating injuries to the abdominal muscles, kidneys, spleen, and liver. (Author/MT)
Epstein, B.M.; Mann, J.H.
Intraabdominal tuberculosis (TB) presents with a wide variety of clinical and radiologic features. Besides the reported computed tomographic (CT) finding of high-density ascites in tuberculous peritonitis, this report describes additional CT features highly suggestive of abdominal tuberculosis in eight cases: (1) irregular soft-tissue densities in the omental area; (2) low-density masses surrounded by thick solid rims; (3) a disorganized appearance of soft-tissue densities, fluid, and bowel loops forming a poorly defined mass; (4) low-density lymph nodes with a multilocular appearance after intravenous contrast administration; and (5) possibly high-density ascites. The differential diagnosis of these features include lymphoma, various forms ofmore » peritonitis, peritoneal carcinomatosis, and peritoneal mesothelioma. It is important that the CT features of intraabdominal tuberculosis be recognized in order that laparotomy be avoided and less invasive procedures (e.g., laparoscopy, biopsy, or a trial of antituberculous therapy) be instituted.« less
Clouse, Ray E; Mayer, Emeran A; Aziz, Qasim; Drossman, Douglas A; Dumitrascu, Dan L; Mönnikes, Hubert; Naliboff, Bruce D
Functional abdominal pain syndrome (FAPS) differs from the other functional bowel disorders; it is less common, symptoms largely are unrelated to food intake and defecation, and it has higher comorbidity with psychiatric disorders. The etiology and pathophysiology are incompletely understood. Because FAPS likely represents a heterogeneous group of disorders, peripheral neuropathic pain mechanisms, alterations in endogenous pain modulation systems, or both may be involved in any one patient. The diagnosis of FAPS is made on the basis of positive symptom criteria and a longstanding history of symptoms; in the absence of alarm symptoms, an extensive diagnostic evaluation is not required. Management is based on a therapeutic physician-patient relationship and empirical treatment algorithms using various classes of centrally acting drugs, including antidepressants and anticonvulsants. The choice, dose, and combination of drugs are influenced by psychiatric comorbidities. Psychological treatment options include psychotherapy, relaxation techniques, and hypnosis. Refractory FAPS patients may benefit from a multidisciplinary pain clinic approach.
... Protect Your Pets Emergency Wound Care After a Natural Disaster Language: English (US) Español (Spanish) Recommend on ... Go Fact Sheet Emergency Wound Care After a Natural Disaster [NOTE: Health professionals should see Emergency Wound ...
To emphasize that the management of wounds represents a significant component within the overall supportive and palliative care of patients with advanced illness. It is also intended to clarify the linguistics that are commonly used around patients with wounds. New paradigms for wound management, wound outcomes, and goal setting have been defined and graphically depicted. Recent studies show that wounds may be used as prognostic factors for patients with advanced illness. Data from recent studies also demonstrate that marginal levels of wound healing are possible for all wound classes affecting patients with advanced illness. When indicated, time-limited trials of wound healing strategies should be facilitated by the Wound Bed Preparation Paradigm. Wound palliation may be guided through the use of the Toronto Symptom Assessment System for Wounds (TSAS-W). Wound management must continue to evolve as a tenet within the overall supportive and palliative care of patients with advanced illness.
Heringer, Rodrigo D; Ranville, James F
Single particle inductively coupled plasma mass spectrometry (spICP-MS) was investigated as a screening-level technique for the analysis and characterization of inorganic gunshot residue (IGSR) nanoparticles. spICP-MS works with undigested samples whereby nanoparticles (NPs) in a suspension are individually atomized and ionized as they reach the plasma, each resulting in a pulse of analyte ions that can be quantified. The method is rapid, and signals from hundreds of NPs can be collected in 1-2min per sample. The technique is quantitative for NP mass and number concentration when only one element (single element mode) is measured using a quadrupole MS. Likewise, a qualitative elemental fingerprint can be obtained for individual NPs when peak-hopping between two elements (dual element mode). For this proof of concept study, each shooter's hand was sampled with ultrapure water or swab to obtain NPs suspensions. Measurements of antimony, barium, and lead were performed using both analysis modes. With no sample preparation and fully automated sample introduction, it is possible to analyze more than 100 samples in a day. Results show that this technique opens a new perspective for future research on GSR sample identification and characterization and can complement SEM/EDX analysis. Copyright © 2018 Elsevier B.V. All rights reserved.
Bueno, Justin; Sikirzhytski, Vitali; Lednev, Igor K
The ability to link a suspect to a particular shooting incident is a principal task for many forensic investigators. Here, we attempt to achieve this goal by analysis of gunshot residue (GSR) through the use of attenuated total reflectance (ATR) Fourier transform infrared spectroscopy (FT-IR) combined with statistical analysis. The firearm discharge process is analogous to a complex chemical process. Therefore, the products of this process (GSR) will vary based upon numerous factors, including the specific combination of the firearm and ammunition which was discharged. Differentiation of FT-IR data, collected from GSR particles originating from three different firearm-ammunition combinations (0.38 in., 0.40 in., and 9 mm calibers), was achieved using projection to latent structures discriminant analysis (PLS-DA). The technique was cross (leave-one-out), both internally and externally, validated. External validation was achieved via assignment (caliber identification) of unknown FT-IR spectra from unknown GSR particles. The results demonstrate great potential for ATR-FT-IR spectroscopic analysis of GSR for forensic purposes.
López-López, María; Delgado, Juan José; García-Ruiz, Carmen
The ability to unequivocally identify a gunshot residue (GSR) when a firearm is discharged is a very important and crucial part of crime scene investigation. To date, the great majority of the analyses have focused on the inorganic components of GSR, but the introduction of "lead-free" or "nontoxic" ammunitions makes it difficult to prevent false negatives. This study introduces a fast methodology for the organic analysis of GSR using Raman spectroscopy. Six different types of ammunition were fired at short distances into cloth targets, and the Raman spectra produced by the GSR were measured and compared with the spectra from the unfired gunpowder ammunition. The GSR spectrum shows high similarity to the spectrum of the unfired ammunition, allowing the GSR to be traced to the ammunition used. Additionally, other substances that might be found on the victim's, shooter's, or suspect's clothes and might be confused with GSR, such as sand, dried blood, or black ink from a common ballpoint pen, were analyzed to test the screening capability of the Raman technique. The results obtained evidenced that Raman spectroscopy is a useful screening tool when fast analysis is desired and that little sample preparation is required for the analysis of GSR evidence.
Gilchrist, Elizabeth; Jongekrijg, Fleur; Harvey, Laura; Smith, Norman; Barron, Leon
Gunshot residue (GSR) is commonly analysed in forensic casework using either scanning electron microscopy with energy-dispersive X-ray spectroscopy (SEM-EDX) or gas chromatography-mass spectrometry (GC-MS). Relatively little work has been reported on the post-discharge GSR content of non-metallic inorganic or low molecular weight organic anions to distinguish between different ammunition types. The development of an analytical method using suppressed micro-bore anion exchange chromatography (IC) is presented for the analysis of GSR. A hydroxide gradient was optimised for the separation of 19 forensically relevant organic and inorganic anions in <23min and sensitivities of the order of 0.12-3.52ng of anion detected for all species were achieved. Along with an optimised extraction procedure, this method was applied to the analysis of post-ignition residues from three selected ammunition types. By profiling and comparing the anionic content in each ammunition residue, the possibility to distinguish between each type using their anionic profiles and absolute weight is presented. The potential for interference is also discussed with respect to sample types which are typically problematic in the analysis of GSR using SEM-EDX and GC-MS. To the best of our knowledge this represents the first study on the analysis of inorganic anions in GSR using suppressed ion chromatography. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Comiskey, Patrick; Yarin, Alexander; Kim, Sungu; Attinger, Daniel
A theoretical model describing the blood back spatter pattern resulting from a blunt bullet gunshot is proposed and compared to experimental data. It is shown that the blunt bullet impact results in blood accelerating towards air opposite of the bullet motion creating a situation for the Rayleigh-Taylor instability which determines droplet sizes and initial velocities. Then, drop trajectories can be predicted accounting for all forces involved: air drag and gravity forces, as well as for the collective effect of drop-drop interaction through air which diminishes the drag force on drops moving in the wake of the others. Experimental data was acquired by shooting a blunt bullet into a porous substrate impregnated with swine blood and the spatter pattern was collected on a vertical surface located between the target and the shooter. The spatter pattern was analyzed for the number of droplets, the area of blood stains, total stain area, and location. Comparisons with the theoretical results reveal satisfactory agreement. The theory also predicts the impact angle at the collection surface, the Weber number corresponding to the drop impact onto the collection surface, and the stain ellipticity. Support of this work by the US National Institute of Justice (award NIJ 2014-DN-BX-K036) is greatly appreciated.
López-López, María; Merk, Virginia; García-Ruiz, Carmen; Kneipp, Janina
Gunshot residues (GSR) result from the discharge of a firearm being a potential piece of evidence in criminal investigations. The macroscopic GSR particles are basically formed by burned and non-burned gunpowder. Motivated by the demand of trace analysis of these samples, in this paper, the use of surface-enhanced Raman scattering (SERS) was evaluated for the analysis of gunpowders and macroscopic GSR particles. Twenty-one different smokeless gunpowders were extracted with ethanol. SERS spectra were obtained from the diluted extracts using gold nanoaggregates and an excitation wavelength of 633 nm. They show mainly bands that could be assigned to the stabilizers diphenylamine and ethylcentralite present in the gunpowders. Then, macroscopic GSR particles obtained after firing two different ammunition cartridges on clothing were also measured using the same procedure. SERS allowed the detection of the particles collected with an aluminum stub from cloth targets without interferences from the adhesive carbon. The results demonstrate the great potential of SERS for the analysis of macroscopic GSR particles. Furthermore, they indicate that the grain-to-grain inhomogeneity of the gunpowders needs to be considered. Graphical Abstract SERS allows the detection of GSR particles collected with adhesive stubs from cloth targets using gold nanoaggregates and an excitation wavelength of 633 nm.
Graves, Jordan R.
For decades, law enforcement organizations have increasingly utilized audio detection and localization systems to identify potential gunshot incidents and to respond accordingly. These systems have grown from simple microphone configurations used to estimate location into complex arrays that seem to pinpoint gunfire to within mere feet of its actual occurrence. Such technology comes from a long and dynamic history of developing equipment dating back to the First World War. Additionally, though basic designs require little in terms of programming or engineering experience, the mere presence of this tool invokes a firestorm of debate amongst economists, law enforcement groups, and the general public, which leads to questions about future possibilities for its use. The following pages will retell the history of these systems from theoretical conception to current capabilities. This work will also dissect these systems to reveal fundamental elements of their inner workings, in order to build a basic demonstrative system. Finally, this work will discuss some legal and moral points of dissension, and will explore these systems’ roles in society now and in the future, in additional applications as well.
Ribeiro, Juliano G. C.; Serrenho, Felipe G.; Apolinário, José A.; Ramos, António L. L.
Spotting a shooter from a drone has been the subject of great interest lately due to its many applications in the fields of defense and security and law enforcement. Using a drone can be an effective way to detect potential threats in many real-life scenarios. Nevertheless, acoustic signals recorded from a drone usually exhibit a very low SNR, mainly due to the distance to the source and the proximity of the sensors to the propellers. This is a serious limiting factor and, therefore, the use of signal enhancement techniques is required. This work addresses the problem of determining the Direction-of-Arrival (DoA) of the muzzle blast, captured using a planar microphone array mounted on a commercial DJI PHANTOM 4 drone in flight. This new shooter localization method that relies solely on detecting and estimating the DoA of the muzzle blast. However, the typical low SNR in this scenario requires the use of preprocessing techniques, such as signal clipping and median filtering, to enhance the signal of interest (muzzle blast). In addition, we employ a recently introduced improved data selection DoA estimation method suitable for gunshot signals recorded from a low to medium altitude mobile aerial platform. Positive results achieved indicate that this approach is effective and of practical interest.
Almost 1/2 century ago, H. E. ``Doc'' Edgerton demonstrated a simple and elegant direct-shadowgraph technique for imaging large-scale events like explosions and gunshots. Only a retroreflective screen, flashlamp illumination, and an ordinary view camera were required. Retroreflective shadowgraphy has seen occasional use since then, but its unique combination of large scale, simplicity and portability has barely been tapped. It functions well in environments hostile to most optical diagnostics, such as full-scale outdoor daylight ballistics and explosives testing. Here, shadowgrams cast upon a 2.4 m square retroreflective screen are imaged by a Photron Fastcam APX-RS digital camera that is capable of megapixel image resolution at 3000 frames/sec up to 250,000 frames/sec at lower resolution. Microsecond frame exposures are used to examine the external ballistics of several firearms, including a high-powered rifle, an AK-47 submachine gun, and several pistols and revolvers. Muzzle blast phenomena and the mechanism of gunpowder residue deposition on the shooter's hands are clearly visualized. In particular, observing the firing of a pistol with and without a silencer (suppressor) suggests that some of the muzzle blast energy is converted by the silencer into supersonic jet noise.
Orakhelashvili, G A; Kapanadze, L P; Bregadze, G I; Kacharava, B D; Dzagnidze, E B
Severe vascular gunshot injury (popliteal artery damage) and fractures of both low extremities are causes traumatic shock (stage III) and anemia in a 32 years female patient. Being the victim of crime, the patient for 5 hours was in a life-threatening condition that could develop the multiple organ system failure (MOSF) as a result of tissue ischemia and reperfusion and acute irreversible shock. There was an urgent necessity to perform three immediate operations at the same time. Successful recovery required rapid control of the inciting event (i.e., maintenance of effective hemodynamic stability and the body's ability to protect its vital organs, choice of the type of anesthesia with certain anesthetics) facilitated by resuscitative therapy directed toward minimizing the overall "dose" of shock. Oxybutirate sodium (a GABA analog, the only one narcotic drug and a natural metabolite of body) administered intravenously as a hypnotic agent and an important component of intensive care as well have had clearly anti-shock and antihypoxant effects. Rapid improving of circulation and using of medications with wide range of anti-stress action (such as oxybutirate sodium, dexamethazone and glucose) assisted successful resuscitation and possibility to perform three operations (duration: 6 hours and 45 minutes). An increasing emphasis was being placed on prevention of MOSF, including 1) maintenance of tissue oxygenation; 2) using above-mentioned anti-stress and antihypoxant medicines with mutually supportive effects and 3) infection control.
Bueno, Justin; Sikirzhytski, Vitali; Lednev, Igor K
Near-infrared (NIR) Raman microspectroscopy combined with advanced statistics was used to differentiate gunshot residue (GSR) particles originating from different caliber ammunition. The firearm discharge process is analogous to a complex chemical reaction. The reagents of this process are represented by the chemical composition of the ammunition, firearm, and cartridge case. The specific firearm parameters determine the conditions of the reaction and thus the subsequent product, GSR. We found that Raman spectra collected from these products are characteristic for different caliber ammunition. GSR particles from 9 mm and 0.38 caliber ammunition, collected under identical discharge conditions, were used to demonstrate the capability of confocal Raman microspectroscopy for the discrimination and identification of GSR particles. The caliber differentiation algorithm is based on support vector machines (SVM) and partial least squares (PLS) discriminant analyses, validated by a leave-one-out cross-validation method. This study demonstrates for the first time that NIR Raman microspectroscopy has the potential for the reagentless differentiation of GSR based upon forensically relevant parameters, such as caliber size. When fully developed, this method should have a significant impact on the efficiency of crime scene investigations.
Schyma, Christian; Lux, Constantin; Madea, Burkhard; Courts, Cornelius
In practical forensic casework, backspatter recovered from shooters' hands can be an indicator of self-inflicted gunshot wounds to the head. In such cases, backspatter retrieved from inside the barrel indicates that the weapon found at the death scene was involved in causing the injury to the head. However, systematic research on the aspects conditioning presence, amount and specific patterns of backspatter is lacking so far. Herein, a new concept of backspatter investigation is presented, comprising staining technique, weapon and target medium: the 'triple contrast method' was developed, tested and is introduced for experimental backspatter analysis. First, mixtures of various proportions of acrylic paint for optical detection, barium sulphate for radiocontrast imaging in computed tomography and fresh human blood for PCR-based DNA profiling were generated (triple mixture) and tested for DNA quantification and short tandem repeat (STR) typing success. All tested mixtures yielded sufficient DNA that produced full STR profiles suitable for forensic identification. Then, for backspatter analysis, sealed foil bags containing the triple mixture were attached to plastic bottles filled with 10% ballistic gelatine and covered by a 2-3-mm layer of silicone. To simulate backspatter, close contact shots were fired at these models. Endoscopy of the barrel inside revealed coloured backspatter containing typable DNA and radiographic imaging showed a contrasted bullet path in the gelatine. Cross sections of the gelatine core exhibited cracks and fissures stained by the acrylic paint facilitating wound ballistic analysis.
Xing, Liyu; Culbertson, Eric J.; Wen, Yuan; Franz, Michael G.
Background Incisional hernia is the most common complication of abdominal surgery leading to reoperation. In the United States, 200,000 incisional hernia repairs are performed annually, often with significant morbidity. Obesity is increasing the risk of laparotomy wound failure. Methods We used a validated animal model of incisional hernia formation. We intentionally induced laparotomy wound failure in otherwise normal adult, male Sprague-Dawley rats. Radio-opaque, metal surgical clips served as markers for the use of x-ray images to follow the progress of laparotomy wound failure. We confirmed radiographic findings of the time course for mechanical laparotomy wound failure by necropsy. Results Noninvasive radiographic imaging predicts early laparotomy wound failure and incisional hernia formation. We confirmed both transverse and craniocaudad migration of radio-opaque markers at necropsy after 28 d that was uniformly associated with the clinical development of incisional hernias. Conclusions Early laparotomy wound failure is a primary mechanism for incisional hernia formation. A noninvasive radiographic method for studying laparotomy wound healing may help design clinical trials to prevent and treat this common general surgical complication. PMID:23036516
To find out if the use of the vascularized temporo-parietal fascial flap (TPFF) reduces postoperative infection or wound breakdown in subtotal petrosectomy for chronic discharging ears. A retrospective review on 26 subtotal petrosectomies with blind pit closures on chronic discharging ears performed by a single surgeon between 2000 and 2015 was performed. All patients had a minimum follow-up period of 6 months. Eleven mastoid cavities were obliterated with abdominal fat, and 15 cavities were obliterated with TPFF. There was no concomitant cochlear implant or middle ear implant. All postoperative wound infections or delay in wound healing were recorded into a database. The complication rates of the fat obliteration group were compared using Fisher's exact test with those for the TPFF obliteration group. In the fat obliteration group, 4 out of 11 patients had documented postoperative complications. Three had wound breakdown with exposure of the fat that required revision surgery. Another patient had postauricular abscess without the wound actually broken down. On the other hand, all the ears in the TPFF obliteration group (100%) were completely free of wound infection, wound breakdown, or any complication. The difference between the two groups was statistically significant (p = 0.022). Many authors have encountered postoperative infection or wound breakdown in subtotal petrosectomy with fat obliteration in the treatment of chronic otitis media. Using a richly vascularized temporo-temporal fascial flap to protect the blind pit closure in such patients reduces postoperative infection and wound breakdown.
Oosthuizen, G V; Kong, V Y; Estherhuizen, T; Bruce, J L; Laing, G L; Odendaal, J J; Clarke, D L
Introduction In light of continuing controversy surrounding the management of penetrating colonic injuries, we set out to compare the outcome of penetrating colonic trauma according to whether the mechanism of injury was a stab wound or a gunshot wound. Methods Our trauma registry was interrogated for the 5-year period from January 2012 to December 2016. All patients over the age of 18 years with penetrating trauma (stab or gunshot) and with intraoperatively proven colonic injury were reviewed. Details of the colonic and concurrent abdominal injuries were recorded, together with the operative management strategy. In-hospital morbidities were divided into colon-related and non-colon related morbidities. The length of hospital stay and mortality were recorded. Direct comparison was made between patients with stab wounds and gunshot wounds to the colon. Results During the 5-year study period, 257 patients sustained a colonic injury secondary to penetrating trauma; 95% (244/257) were male and the mean age was 30 years. A total of 113 (44%) sustained a gunshot wound and the remaining 56% (144/257) sustained a stab wound. Some 88% (226/257) of all patients sustained a single colonic injury, while 12% (31/257) sustained more than one colonic injury. A total of 294 colonic injuries were found at laparotomy. Multiple colonic injuries were less commonly encountered in stab wounds (6%, 9/144 vs. 19%, 22/113, P < 0.001). Primary repair was more commonly performed for stab wounds compared with gunshot wounds (118/144 vs. 59/113, P < 0.001). Patients with gunshot wounds were more likely to need admission to intensive care, more likely to experience anastomotic failure, and had higher mortality. Conclusions It would appear that colonic stab wounds and colonic gunshot wounds are different in terms of severity of the injury and in terms of outcome. While primary repair is almost always applicable to the management of colonic stab wounds, the same cannot be said for colonic
Zhang, Shiwu; Gnyawali, Surya; Huang, Jiwei; Liu, Peng; Gordillo, Gayle; Sen, Chandan K.; Xu, Ronald
The wound healing process involves the reparative phases of inflammation, proliferation, and remodeling. Interrupting any of these phases may result in chronically unhealed wounds, amputation, or even patient death. Quantitative assessment of wound tissue ischemia, perfusion, and inflammation provides critical information for appropriate detection, staging, and treatment of chronic wounds. However, no method is available for noninvasive, simultaneous, and quantitative imaging of these tissue parameters. We integrated hyperspectral, laser speckle, and thermographic imaging modalities into a single setup for multimodal assessment of tissue oxygenation, perfusion, and inflammation characteristics. Advanced algorithms were developed for accurate reconstruction of wound oxygenation and appropriate co-registration between different imaging modalities. The multimodal wound imaging system was validated by an ongoing clinical trials approved by OSU IRB. In the clinical trial, a wound of 3mm in diameter was introduced on a healthy subject's lower extremity and the healing process was serially monitored by the multimodal imaging setup. Our experiments demonstrated the clinical usability of multimodal wound imaging.
Falabella, Anna F
Debridement can play a vital role in wound bed preparation and the removal of barriers that impair wound healing. In accordance with the TIME principles, debridement can help remove nonviable tissue, control inflammation or infection, decrease excess moisture, and stimulate a nonadvancing wound edge. There are many types of debridement, each with a set of advantages and disadvantages that must be clearly understood by the healthcare team. Failure to use the correct debridement method for a given type of wound may lead to further delays in healing, increase patient suffering, and unnecessarily increase the cost of care. This review article discusses the various methods of debridement, describes currently available debriding agents, evaluates the clinical data regarding their efficacy and safety, and describes strategies for the management of problematic nonhealing wounds.
Omar, Amin; Wright, J. Barry; Schultz, Gregory; Burrell, Robert; Nadworny, Patricia
Background is provided on biofilms, including their formation, tolerance mechanisms, structure, and morphology within the context of chronic wounds. The features of biofilms in chronic wounds are discussed in detail, as is the impact of biofilm on wound chronicity. Difficulties associated with the use of standard susceptibility tests (minimum inhibitory concentrations or MICs) to determine appropriate treatment regimens for, or develop new treatments for use in, chronic wounds are discussed, with alternate test methods specific to biofilms being recommended. Animal models appropriate for evaluating biofilm treatments are also described. Current and potential future therapies for treatment of biofilm-containing chronic wounds, including probiotic therapy, virulence attenuation, biofilm phenotype expression attenuation, immune response suppression, and aggressive debridement combined with antimicrobial dressings, are described. PMID:28272369
Horng, Huann-Cheng; Chang, Wen-Hsun; Yeh, Chang-Ching; Huang, Ben-Shian; Chang, Chia-Pei; Chen, Yi-Jen; Tsui, Kuan-Hao
Wound healing is a physiological process, involving three successive and overlapping phases—hemostasis/inflammation, proliferation, and remodeling—to maintain the integrity of skin after trauma, either by accident or by procedure. Any disruption or unbalanced distribution of these processes might result in abnormal wound healing. Many molecular and clinical data support the effects of estrogen on normal skin homeostasis and wound healing. Estrogen deficiency, for example in postmenopausal women, is detrimental to wound healing processes, notably inflammation and re-granulation, while exogenous estrogen treatment may reverse these effects. Understanding the role of estrogen on skin might provide further opportunities to develop estrogen-related therapy for assistance in wound healing. PMID:29099810
Hanna, Dominique; Cloutier, Richard; Lapointe, Roch; Desgagné, Antoine
Elephantiasis is a well-known condition in dermatology usually affecting the legs and external genitalia. It is characterized by chronic inflammation and obstruction of the lymphatic channels and by hypertrophy of the skin and subcutaneous tissues. The etiology is either idiopathic or caused by a variety of conditions such as chronic filarial disease, leprosy, leishmaniasis, and chronic recurrent cellulites. Elephantiasis of the abdominal wall is very rare. A complete review of the English and French literature showed only two cases reported in 1966 and 1973, respectively. We report a third case of abdominal elephantiasis and we briefly review this entity. We present the case of a 51-year-old woman who had progressively developed an enormous pediculated abdominal mass hanging down her knees. The skin was thickened, hyperpigmented, and fissured. She had a history of multiple abdominal cellulites. She underwent an abdominal lipectomy. Histopathology of the specimen confirmed the diagnosis of abdominal elephantiasis. Abdominal elephantiasis is a rare disease that represents end-stage failure of lymph drainage. Lipectomy should be considered in the management of this condition.
Hsu, Jui-Tse; Ho, Te-Wei; Shih, Hsueh-Fu; Chang, Chun-Che; Lai, Feipei; Wu, Jin-Ming
With the growing demand for more efficient wound care after surgery, there is a necessity to develop a machine learning based image analysis approach to reduce the burden for health care professionals. The aim of this study was to propose a novel approach to recognize wound infection on the postsurgical site. Firstly, we proposed an optimal clustering method based on unimodal-rosin threshold algorithm to extract the feature points from a potential wound area into clusters for regions of interest (ROI). Each ROI was regarded as a suture site of the wound area. The automatic infection interpretation based on the support vector machine is available to assist physicians doing decision-making in clinical practice. According to clinical physicians' judgment criteria and the international guidelines for wound infection interpretation, we defined infection detector modules as the following: (1) Swelling Detector, (2) Blood Region Detector, (3) Infected Detector, and (4) Tissue Necrosis Detector. To validate the capability of the proposed system, a retrospective study using the confirmation wound pictures that were used for diagnosis by surgical physicians as the gold standard was conducted to verify the classification models. Currently, through cross validation of 42 wound images, our classifiers achieved 95.23% accuracy, 93.33% sensitivity, 100% specificity, and 100% positive predictive value. We believe this ability could help medical practitioners in decision making in clinical practice.
... your home is safe as you are recovering . Wound Care Change the dressing over your surgical wound once a day, or sooner if it becomes ... when you do not need to keep your wound covered. Keep the wound area clean . You may ...
Bower, Curtis; Roth, J Scott
The economic aspects of abdominal wall reconstruction are frequently overlooked, although understandings of the financial implications are essential in providing cost-efficient health care. Ventral hernia repairs are frequently performed surgical procedures with significant economic ramifications for employers, insurers, providers, and patients because of the volume of procedures, complication rates, the significant rate of recurrence, and escalating costs. Because biological mesh materials add significant expense to the costs of treating complex abdominal wall hernias, the role of such costly materials needs to be better defined to ensure the most cost-efficient and effective treatments for ventral abdominal wall hernias. Copyright © 2013 Elsevier Inc. All rights reserved.
Alwan, Riham; Drake, Meredith; Gurria Juarez, Juan; Emery, Kathleen H; Shaaban, Aimen F; Szabo, Sara; Sobolewski, Brad
A previously healthy 3-week-old boy presented with 5 hours of marked fussiness, abdominal distention, and poor feeding. He was afebrile and well perfused. His examination was remarkable for localized abdominal tenderness and distention. He was referred to the emergency department in which an abdominal radiograph revealed gaseous distention of the bowel with a paucity of gas in the pelvis. Complete blood cell count and urinalysis were unremarkable. His ongoing fussiness and abnormal physical examination prompted consultation with surgery and radiology. Our combined efforts ultimately established an unexpected diagnosis. Copyright © 2017 by the American Academy of Pediatrics.
Rodríguez-Villalobos, Jenny Carolina; Work, Thierry M.; Calderon-Aguileraa, Luis Eduardo
Corals routinely lose tissue due to causes ranging from predation to disease. Tissue healing and regeneration are fundamental to the normal functioning of corals, yet we know little about this process. We described the microscopic morphology of wound repair in Pocillopora damicornis. Tissue was removed by airbrushing fragments from three healthy colonies, and these were monitored daily at the gross and microscopic level for 40 days. Grossly, corals healed by Day 30, but repigmentation was not evident at the end of the study (40 d). On histology, from Day 8 onwards, tissues at the lesion site were microscopically indistinguishable from adjacent normal tissues with evidence of zooxanthellae in gastrodermis. Inflammation was not evident. P. damicornis manifested a unique mode of regeneration involving projections of cell-covered mesoglea from the surface body wall that anastomosed to form gastrovascular canals.
Istvan, Stephanie A; Walker, Julie M; Hansen, Bernard D; Hanel, Rita M; Marks, Steven L
To describe the clinical features, diagnostic findings, treatment, and outcome of a dog with acute abdominal pain and hemoperitoneum secondary to a presumptive intraperitoneal (IP) snakebite. A 10-month-old castrated male mixed-breed dog was evaluated for suspected snake envenomation. The dog presented recumbent and tachycardic with signs of severe abdominal pain. Two cutaneous puncture wounds and hemoperitoneum were discovered during evaluation. Ultrasonographic examination revealed communication of the wounds with the peritoneal cavity. The dog was treated with supportive care, parenteral analgesia, packed red blood cell and fresh frozen plasma transfusions, crotalid antivenom, and placement of an IP catheter to provide local analgesia. The dog recovered fully and was discharged 5 days after initial presentation. To our knowledge, this is the first report of IP envenomation accompanied by hemorrhage treated with continuous IP analgesia in the veterinary literature. © Veterinary Emergency and Critical Care Society 2015.
Maegdefessel, Lars; Spin, Joshua M.; Adam, Matti; Raaz, Uwe; Toh, Ryuji; Nakagami, Futoshi; Tsao, Philip S.
The contribution of abdominal aortic aneurysm (AAA) disease to human morbidity and mortality has increased in the aging, industrialized world. In response, extraordinary efforts have been launched to determine the molecular and pathophysiological characteristics of the diseased aorta. This work aims to develop novel diagnostic and therapeutic strategies to limit AAA expansion and, ultimately, rupture. Contributions from multiple research groups have uncovered a complex transcriptional and post-transcriptional regulatory milieu, which is believed to be essential for maintaining aortic vascular homeostasis. Recently, novel small noncoding RNAs, called microRNAs, have been identified as important transcriptional and post-transcriptional inhibitors of gene expression. MicroRNAs are thought to “fine tune” the translational output of their target messenger RNAs (mRNAs) by promoting mRNA degradation or inhibiting translation. With the discovery that microRNAs act as powerful regulators in the context of a wide variety of diseases, it is only logical that microRNAs be thoroughly explored as potential therapeutic entities. This current review summarizes interesting findings regarding the intriguing roles and benefits of microRNA expression modulation during AAA initiation and propagation. These studies utilize disease-relevant murine models, as well as human tissue from patients undergoing surgical aortic aneurysm repair. Furthermore, we critically examine future therapeutic strategies with regard to their clinical and translational feasibility. PMID:23852016
Mortimer, Alice Emily
A 79-year-old woman presented to a private medical practice 2 years previously for an elective ultrasound screening scan. This imaging provided the evidence for a diagnosis of an abdominal aortic aneurysm (AAA) to be made. Despite having a number of recognised risk factors for an AAA, her general practitioner at the time did not follow the guidance set out by the private medical professional, that is, to refer the patient to a vascular specialist to be entered into a surveillance programme and surgically evaluated. The patient became symptomatic with her AAA, was admitted to hospital and found to have a tender, symptomatic, 6 cm leaking AAA. She consented for an emergency open AAA repair within a few hours of being admitted to hospital, despite the 50% perioperative mortality risk. The patient spent 4 days in intensive care where she recovered well. She was discharged after a 12 day hospital stay but unfortunately passed away shortly after her discharge from a previously undiagnosed gastric cancer. 2014 BMJ Publishing Group Ltd.
Mortimer, Alice Emily
A 79-year-old woman presented to a private medical practice 2 years previously for an elective ultrasound screening scan. This imaging provided the evidence for a diagnosis of an abdominal aortic aneurysm (AAA) to be made. Despite having a number of recognised risk factors for an AAA, her general practitioner at the time did not follow the guidance set out by the private medical professional, that is, to refer the patient to a vascular specialist to be entered into a surveillance programme and surgically evaluated. The patient became symptomatic with her AAA, was admitted to hospital and found to have a tender, symptomatic, 6 cm leaking AAA. She consented for an emergency open AAA repair within a few hours of being admitted to hospital, despite the 50% perioperative mortality risk. The patient spent 4 days in intensive care where she recovered well. She was discharged after a 12 day hospital stay but unfortunately passed away shortly after her discharge from a previously undiagnosed gastric cancer. PMID:25398912
Testini, Mario; Piccinni, Giuseppe; Pedote, Pasquale; Lissidini, Germana; Gurrado, Angela; Lardo, Domenica; Greco, Luigi; Marzaioli, Rinaldo
Shotgun injuries are the cause of increasing surgical problems related to the proliferation of firearms. Gunshot pancreaticoduodenal traumas are unusual in urban trauma units. Their management remains complex because of the absence of standardized, universal guidelines for treatment and the high incidence of associated lesions of major vessels as well as of other gastrointestinal structures. Surgical treatment is still controversial, and the possibilities offered by the safe and effective mini-invasive techniques seem to open new, articulated perspectives for the treatment of pancreaticoduodenal injury complications. We present the case of a 27-year-old man with multiple penetrating gunshot trauma evolving into acute necrotizing pancreatitis, treated by combining a surgical with a mini-invasive approach. At admission, he presented a Glasgow Coma Score of 4 due to severe hemorrhagic shock. First, surgical hemostasis, duodenogastric resection, multiple intestinal resections, peripancreatic and thoracic drainage were carried out as emergency procedures. On the 12th postoperative day, the patient underwent re-surgery with toilette, external duodenal drainage with Foley tube and peripancreatic drainage repositioning as a result of a duodenal perforation due to acute necrotizing pancreatitis. Eight days later, following the accidental removal of the peripancreatic drains, a CT scan was done showing a considerable collection of fluid in the epiploon retrocavity. Percutaneous CT-guided drainage was performed by inserting an 8.5 Fr pigtail catheter, thus avoiding further re-operation. The patient was successfully discharged on the 80th postoperative day. The treatment of multiple pancreaticoduodenal penetrating gunshot traumas should focus on multidisciplinary surgical and minimally invasive treatment to optimize organ recovery.
Valero, C.; Javierre, E.; García-Aznar, J. M.; Gómez-Benito, M. J.; Menzel, A.
Biological soft tissues exhibit non-linear complex properties, the quantification of which presents a challenge. Nevertheless, these properties, such as skin anisotropy, highly influence different processes that occur in soft tissues, for instance wound healing, and thus its correct identification and quantification is crucial to understand them. Experimental and computational works are required in order to find the most precise model to replicate the tissues' properties. In this work, we present a wound healing model focused on the proliferative stage that includes angiogenesis and wound contraction in three dimensions and which relies on the accurate representation of the mechanical behavior of the skin. Thus, an anisotropic hyperelastic model has been considered to analyze the effect of collagen fibers on the healing evolution of an ellipsoidal wound. The implemented model accounts for the contribution of the ground matrix and two mechanically equivalent families of fibers. Simulation results show the evolution of the cellular and chemical species in the wound and the wound volume evolution. Moreover, the local strain directions depend on the relative wound orientation with respect to the fibers.
Madhok, Brijesh M; Vowden, Kathryn; Vowden, Peter
Debridement is a crucial component of wound management. Traditionally, several types of wound debridement techniques have been used in clinical practice such as autolytic, enzymatic, biodebridement, mechanical, conservative sharp and surgical. Various factors determine the method of choice for debridement for a particular wound such as suitability to the patient, the type of wound, its anatomical location and the extent of debridement required. Recently developed products are beginning to challenge traditional techniques that are currently used in wound bed preparation. The purpose of this review was to critically evaluate the current evidence behind the use of these newer techniques in clinical practice. There is some evidence to suggest that low frequency ultrasound therapy may improve healing rates in patients with venous ulcers and diabetic foot ulcers. Hydrosurgery debridement is quick and precise, but the current evidence is limited and further studies are underway. Debridement using a monofilament polyester fibre pad and plasma-mediated bipolar radiofrequency ablation are both very new techniques. The initial evidence is limited, and further studies are warranted to confirm their role in management of chronic wounds. © 2013 The Authors. International Wound Journal © 2013 John Wiley & Sons Ltd and Medicalhelplines.com Inc.
Sandy-Hodgetts, Kylie; Watts, Robin
The treatment of post-surgical wound complications, such as surgical site infections and surgical wound dehiscence, generates a significant burden for patients and healthcare systems. The effectiveness of negative pressure wound therapy has been under investigation but to date no systematic review has been published in relation to its effectiveness in the prevention of surgical wound complications. To identify the effectiveness of negative pressure wound therapy in the prevention of post-surgical wound complications in adults with a closed surgical incision compared to standard surgical dressings. Male and female adults who have had negative pressure wound therapy applied to their surgical incision following a procedure in one of the following areas: trauma, cardiothoracic, orthopedic, abdominal, or vascular surgery.The intervention of interest was the use of negative pressure wound therapy directly over an incision following a surgical procedure; the comparator was standard surgical dressings.Both experimental and epidemiological study designs, including randomized controlled trials, pseudo-randomized trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical cross sectional studies were sought.The primary outcome was the occurrence of post-surgical wound infection or dehiscence as measured by the following: surgical site infections - superficial and deep; surgical wound dehiscence; wound pain; wound seroma; wound hematoma. Published and unpublished studies in English from 1990 to 2013 were identified by searching a variety of electronic databases. Reference lists of all papers selected for retrieval were then searched for additional studies. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of
Sahbaz, Ahmet; Aynioglu, Oner; Isik, Hatice; Ozmen, Ulku; Cengil, Osman; Gun, Banu Dogan; Gungorduk, Kemal
Peritoneal adhesions are pathological fibrous connections between peritoneal surfaces resulting from incomplete peritoneal repair. Adhesions cause various health problems ranging from pelvic pain and bowel obstruction to infertility. To date, no effective agent exists for intra-abdominal adhesion prevention. Bromelain is the crude extract of the pineapple and it has fibrinolytic, antithrombotic, and anti-inflammatory properties. Bromelain has been shown to be effective for removing necrotic tissues and has been found to be effective for treating various wounds, inflammatory conditions, and thrombotic pathologies. In the present study, we evaluated bromelain as a novel agent for preventing intra-abdominal adhesions. Group 1 (control group): Adhesions were produced by cecal abrasion method, and no treatment was applied. Group 2 (i.p. bromelain-treated group): After adhesion formation, 10 mg/kg/BW of bromelain dissolved in 1 mL saline solution was applied intraperitoneally for 10 days. Group 3 (i.p. saline-treated group): After adhesion formation, 1 mL saline solution was applied intraperitoneally for 10 days. On postoperative day 10, all animals were sacrificed. All 30 rats survived surgery. Throughout the follow-up period, no complications were observed. Statistically significant differences were found between the groups with regards to macroscopic adhesion scores, inflammation, fibrosis and neo-vascularization (p < 0.001, <0.001, p = 0.001, p = 0.002, respectively). Macroscopic and histopathologic (inflammation, fibrosis, neo-vascularization) adhesion scores were lowest in the bromelain-treated group. Bromelain, acting through its barrier, anti-inflammatory, antioxidant, and proteolytic effects and without increasing bleeding tendency or having any adverse effects on wound healing, may be a suitable agent for intra-abdominal adhesion prevention. Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Bozhchenko, A P; Tolmachev, I A
The professional activity of professor V.L. Popov is considered with special reference to the major achievements of himself and his disciples in the field of forensic medical ballistics. The essence of provisions formulated by V.L. Popov on the mechanisms of formation and extent of gunshot injuries is discussed with regard to their importance for the determination of the large shooting distance. V.L. Popov is the founder of the scientific and pedagogical school that was justifiably regarded as the largest in this country and remains as such. The main achievements of this school have been obtained in studies of gunshot injuries.
Davis, Suja P
Patients face various possible complications after abdominal surgery. This article examines best practice in guiding and teaching them how to use an incentive spirometer to facilitate recovery and prevent respiratory complications.
... signs or symptoms of an abdominal aortic aneurysm (AAA). The final recommendation statement summarizes what the Task ... the potential benefits and harms of screening for AAA: (1) Men ages 65 to 75 who smoke ...
Dabbagh, Ali; Mar'ashi, Ali S; Malek, Bahman
A 75-year-old man referred to the outpatient vascular surgery clinic of Taleghani Hospital (Shaheed Beheshti University of Medicine, Tehran, Iran) due to a local nontender mass in his groin. In his history, it was discovered that the mass had appeared a few months after a gunshot injury. He had a history of shortness of breath with a New York Heart Association functional class fluctuating between II and III, but no history of smoking or addiction. In the physical examination, a 5-cm by 5-cm nonpulsatile mass with engorged vessels was found in the anterior portion of the left groin, which was not tender. An elective arterial angiography revealed an arteriovenous fistula joining the femoral artery to the femoral vein at the left groin. The cardiac assessments revealed cor pulmonale (with a restrictive pattern and diastolic dysfunction) and pulmonary hypertension due to primary pulmonary dysfunction. The patient was anesthetized with a balanced general anesthesia method, considering all relevant cardiac and respiratory monitoring methods and specially withholding drugs increasing pulmonary vascular bed pressure, suppressing the myocardium, or increasing the regurgitant flow across the mitral and, especially, the tricuspid valve. The moment the fistula was closed, a rapid fall in the patient's heart rate was noted, from approximately 60 beats per minute to above 40 beats per minute; this decreased heart rate continued up to a few hours after the surgery and did not accompany any significant hemodynamic derangement including the patient's blood pressure. The patient received his postoperative care in the ordinary surgical ward and was discharged a few days later.
Moon, In Seok
Noise-induced hearing loss is a preventive disease and yet the effective treatment modality has not been established. Acute acoustic traumas caused by an exposure to gunshot noise are common in young South Korean males in military service. Considering the significant lack of awareness on this serious issue as well as the absence of proper protective gear, an in-depth analysis is desperately needed. All 3650 soldiers performed regular periodic gunfire exercise without any hearing protective measures. Seven patients with hearing impairment after periodic gunfire visited the aeromedical squadron; all were right-handed males. Six were tested with the K-2 rifle and one was tested with a K-5 revolver. History taking, physical examination, pure-tone audiometry, and impedance audiometry were conducted. In the next periodic gunfire exercise, all 3650 soldiers performed gunfire with unilateral hearing protection. The average outcome of postexposure air conduction thresholds was 6.5 dB in the right ear and 33.1 dB in the left ear. After medical treatment, hearing impairment was much improved; however, tinnitus was not diminished. In the next periodic gunfire exercise, the result of a supplement of unilateral earplug protection proved its effectiveness on acoustic trauma caused by gunfire noise. Asymmetry in hearing loss is related to the position of the head during gunfire. A unilateral hearing protection device was enough to protect hearing from gunfire noise. At the same time, it can effectively prevent a potential firearm accident that can be caused by trainees mishearing the instruction of a firearm instructor if both earplugs are worn. Thus, providing a unilateral earplug for protection against acoustic trauma must be taken into serious consideration.
López-López, María; Alvarez-Llamas, César; Pisonero, Jorge; García-Ruiz, Carmen; Bordel, Nerea
The study of gunshot residue (GSR) patterns can assist in the reconstruction of shooting incidences. Currently, there is a real need of methods capable of furnishing simultaneous elemental analysis with higher specificity for the GSR pattern visualization. Laser-Induced Breakdown Spectroscopy (LIBS) provides a multi-elemental analysis of the sample, requiring very small amounts of material and no sample preparation. Due to these advantages, this study aims at exploring the potential of LIBS imaging for the visualization of GSR patterns. After the spectral characterization of individual GSR particles, the distribution of Pb, Sb and Ba over clothing targets, shot from different distances, were measured in laser raster mode. In particular, an array of spots evenly spaced at 800μm, using a stage displacement velocity of 4mm/s and a laser frequency of 5Hz was employed (e.g. an area of 130×165mm 2 was measured in less than 3h). A LIBS set-up based on the simultaneous use of two spectrographs with iCCD cameras and a motorized stage was used. This set-up allows obtaining information from two different wavelength regions (258-289 and 446-463nm) from the same laser induced plasma, enabling the simultaneous detection of the three characteristic elements (Pb, Sb, and Ba) of GSR particles from conventional ammunitions. The ability to visualize the 2D distribution GSR pattern by LIBS may have an important application in the forensic field, especially for the ballistics area. Copyright © 2017 Elsevier B.V. All rights reserved.
Comiskey, P. M.; Yarin, A. L.; Attinger, D.
A theoretical model describing the blood spatter pattern resulting from a blunt bullet gunshot is proposed. The predictions are compared to experimental data acquired in the present work. This hydrodynamic problem belongs to the class of the impact hydrodynamics with the pressure impulse generating the blood flow. At the free surface, the latter is directed outwards and accelerated toward the surrounding air. As a result, the Rayleigh-Taylor instability of the flow of blood occurs, which is responsible for the formation of blood drops of different sizes and initial velocities. Thus, the initial diameter, velocity, and acceleration of the atomized blood drops can be determined. Then, the equations of motion are solved, describing drop trajectories in air accounting for gravity, and air drag. Also considered are the drop-drop interactions through air, which diminish air drag on the subsequent drops. Accordingly, deposition of two-phase (blood-drop and air) jets on a vertical cardstock sheet located between the shooter and the target (and perforated by the bullet) is predicted and compared with experimental data. The experimental data were acquired with a porous polyurethane foam sheet target impregnated with swine blood, and the blood drops were collected on a vertical cardstock sheet which was perforated by the blunt bullet. The highly porous target possesses a low hydraulic resistance and therefore resembles a pool of blood shot by a blunt bullet normally to its free surface. The back spatter pattern was predicted numerically and compared to the experimental data for the number of drops, their area, the total stain area, and the final impact angle as functions of radial location from the bullet hole in the cardstock sheet (the collection screen). Comparisons of the predicted results with the experimental data revealed satisfactory agreement. The predictions also allow one to find the impact Weber number on the collection screen, which is necessary to predict stain
Gusarov, A A; Makarov, I Yu; Fetisov, V A
The authors present an example from the expert practice demonstrating the influence of such factors as the properties of the ammunition fired from a weapon (including its weight, size, shape, and speed) as well as the anatomical features of the body tissues being affected on the mechanism of formation of a gunshot wound in the human body. The investigation of the suicide of subject P. has demonstrated the penetrating bullet wound of the neck and the head. The entrance wound was located at the anterior neck surface and the exit one in the left half of the occipital region. The examination of the cranial bones revealed perforating fractures of the cribriform and occipital bones. A specific feature of the case under consideration was a change in the bullet direction during its passage through the cribriform bone that made up the internal osseous barrier. A result the initially vertical wound canal turned into the horizontal one within the cerebral cranium and looked on the whole like a zigzag line. The present observation confirms the possibility of a marked change in the direction of the bullet's trajectory in the cranial cavity even when a 9.0 mm bullet fired from the Makarov pistol hits a relatively soft internal bone structure.
COW 03 PUBLICATION REPORT 94-30227 * ABDOMINAL TUBERCULOSIS IN CAIRO, BY RWIavni 0. IHibbs6 M. Kuanmm ad Z. Fun .Y .~ ... W I Form ApprovedREPORT...Fever Hospital, Cairo, In the past, abdominal tuberculous ýileocaecal: was Egypt, are prospectively evaluated by the US Naval one of the commonest forms...8217. females of child-bearing age) indicated that 9 of 20 40%, were diagnosed as extrapulmonary tuberculosis. isolates from 91 tuberculous peritonitis
Broyles, Justin M; Abt, Nicholas B; Sacks, Justin M; Butler, Charles E
Complex abdominal defects are difficult problems encountered by surgeons in multiple specialties. Although current evidence supports the primary repair of these defects with mesh reinforcement, it is unclear which mesh is superior for any given clinical scenario. The purpose of this review was to explore the characteristics of and clinical relevance behind bioprosthetic tissue matrices in an effort to better clarify their role in abdominal wall reconstruction. We reviewed the peer-reviewed literature on the use of bioprosthetic mesh in human subjects. Basic science articles and large retrospective and prospective reviews were included in author's analysis. The clinical performance and characteristics of 13 bioprosthetic tissue matrices were evaluated. The majority of the products evaluated perform well in contaminated fields, where the risk of wound-healing difficulties is high. Clinical outcomes, which included infection, reherniation, and bulge formation, were variable, and the majority of the studies had a mean follow-up of less than 24 months. Although bioprosthetic matrix has a multitude of indications within the growing field of abdominal wall reconstruction, the functionality, regenerative capacity, and long-term fate of these products have yet to be fully established. Furthermore, the clinical performance, indications, and contraindications for each type of matrix need to be fully evaluated in long-term outcome studies.
Broyles, Justin M.; Abt, Nicholas B.; Sacks, Justin M.
Background: Complex abdominal defects are difficult problems encountered by surgeons in multiple specialties. Although current evidence supports the primary repair of these defects with mesh reinforcement, it is unclear which mesh is superior for any given clinical scenario. The purpose of this review was to explore the characteristics of and clinical relevance behind bioprosthetic tissue matrices in an effort to better clarify their role in abdominal wall reconstruction. Methods: We reviewed the peer-reviewed literature on the use of bioprosthetic mesh in human subjects. Basic science articles and large retrospective and prospective reviews were included in author’s analysis. The clinical performance and characteristics of 13 bioprosthetic tissue matrices were evaluated. Results: The majority of the products evaluated perform well in contaminated fields, where the risk of wound-healing difficulties is high. Clinical outcomes, which included infection, reherniation, and bulge formation, were variable, and the majority of the studies had a mean follow-up of less than 24 months. Conclusions: Although bioprosthetic matrix has a multitude of indications within the growing field of abdominal wall reconstruction, the functionality, regenerative capacity, and long-term fate of these products have yet to be fully established. Furthermore, the clinical performance, indications, and contraindications for each type of matrix need to be fully evaluated in long-term outcome studies. PMID:25289285
Schonfeld, Deborah; Lee, Lois K
This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.
Takeo, Makoto; Lee, Wendy; Ito, Mayumi
The skin is a complex organ consisting of the epidermis, dermis, and skin appendages, including the hair follicle and sebaceous gland. Wound healing in adult mammals results in scar formation without any skin appendages. Studies have reported remarkable examples of scarless healing in fetal skin and appendage regeneration in adult skin following the infliction of large wounds. The models used in these studies have offered a new platform for investigations of the cellular and molecular mechanisms underlying wound healing and skin regeneration in mammals. In this article, we will focus on the contribution of skin appendages to wound healing and, conversely, skin appendage regeneration following injuries. Copyright © 2015 Cold Spring Harbor Laboratory Press; all rights reserved.
Zhou, Kehua; Krug, Kenneth; Brogan, Michael S.
Abstract Management of chronic wounds remains unsatisfactory in terms of treatment cost and time required for complete wound closure (CWC). This study aimed to calculate the healing rates, estimated cost, and time required for CWC in wounds; compare estimated wound care costs between healing and nonhealing wounds; and compare cost effectiveness between venous leg ulcer (VLU) and non-VLU. This was a retrospective cohort study performed at a physical therapy (PT) wound care clinic. Deidentified patient data in the electronic medical database from September 10, 2012 to January 23, 2015 were extracted. Among 159 included patients with wounds, 119 (74.84%) patients were healed with CWC. The included patients were treated for 109.70 ± 95.70 days, 29.71 ± 25.66 visits, and at the costs per treatment episode of $1629.65 ± 1378.82 per reimbursement rate and $2711.42 ± 2356.81 per breakeven rate. For patients with CWC (healing group), the treatment duration was 98.01 ± 76.12 days with the time for CWC as 72.45 ± 64.21 days; the cost per treatment episode was $1327.24 ± 1143.53 for reimbursement rate and $2492.58 ± 2106.88 for breakeven cost. For patients with nonhealing wounds, treatment duration was found to be longer with costs significantly higher (P < 0.01 for all). In the healing group, no differences were found between VLU and non-VLU in treatment duration (95.46 days vs. 100.88 days, P = 0.698), time for CWC (68.06 days vs. 77.38 days, P = 0.431), and cost ($2756.78 vs. 2397.84 for breakeven rate, P = 0.640) with the exception of wound dressing costs ($329.19 vs. 146.47, P = 0.001). Healing rates may be affected with patient exclusions. Costs at physicians’ offices were not included. Incorporation of PT in wound care appeared to be cost effective. PT may thus be a good referral option for patients with wounds. However, the results should be interpreted cautiously and further studies are warranted. PMID
Carey, M E
One hundred and forty-three soldiers who received ballistic injury were actively treated at U.S. Army Seventh Corps hospitals during Operation Desert Storm. Ninety-five percent were wounded by fragments, 5% by bullets. Many had wounds of several body parts, including 17.3% who received a head wound; 4.3% a neck wound; 5.8% a chest wound; 9.3% an abdominal wound; and 90% who had extremity wounds. Three hospital deaths occurred--a 2.1% mortality rate. Only two soldiers sustained a brain wound; in both, the missile entered below the skull area protected by the Kevlar helmet. One brainwounded individual was treated and lived; the other died from hemorrhage and shock from concomitant traumatic lower-extremity amputations. The current U.S. helmet appears to provide significant protection from fragmenting ordnance as does the armored vest. Hemorrhage from proximal extremity wounds caused hospital deaths. Treatment of such wounds will have to be improved to reduce future combat mortality.
Rickman, John M; Smith, Martin J
Recent years have seen increasing involvement by forensic anthropologists in the interpretation of skeletal trauma. With regard to ballistic injuries, there is now a large literature detailing gross features of such trauma; however, less attention has been given to microscopic characteristics. This article presents analysis of experimentally induced gunshot trauma in animal bone (Bos taurus scapulae) using full metal jacket (FMJ), soft point (SP), and captive bolt projectiles. The results were examined using scanning electron microscopy (SEM). Additional analysis was conducted on a purported parietal gunshot lesion in a human cranial specimen. A range of features was observed in these samples suggesting that fibrolamellar bone response to projectile impact is analogous to that observed in synthetic composite laminates. The results indicate that direction of bullet travel can be discerned microscopically even when it is ambiguous on gross examination. It was also possible to distinguish SP from FMJ lesions. SEM analysis is therefore recommended as a previously underexploited tool in the analysis of ballistic trauma. © 2014 American Academy of Forensic Scien