Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes

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  • 1. Objectives Discuss some basic principles of ballistics and tissue injury Review basic management principles for extremity gunshot wounds  In the field and definitive care
  • 2. Factors inTissue Injury K = mv2 2E K= Kinetic Energy m= mass V= velocity
  • 3. Caliber Inside diameter of the barrel of the gun  Expressed in hundredths of inches  Ex:  .38 caliber  .22 caliber
  • 4. Caliber Matters? 12 G .45 .38 .32 .22
  • 5. Mass Matters Weight 12-15 g 250-350 8.7 – 10.2 g 230-4 1.7-1.9 g 250-350 Velocity (m/s)
  • 6. Cavitation Formation and then immediate implosion of cavities in a liquid that are the consequence of forces acting upon the liquid.
  • 7. Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
  • 8. Fragmentation Tissue injury also proportional to the cross sectional area of the missile
  • 9. .38 Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
  • 10. .357 Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
  • 11. .22 Long Rifle
  • 12. .306 Long Rifle
  • 13. 12 G Shotgun
  • 14. Management of gunshot wounds to the extremities
  • 15. Hemorrhage Control in the Field Direct pressure or compression dressings preferred and often successful Avoid “clamping” Consider the use of a tourniquet
  • 16. Tourniquets
  • 17. Tourniquets Use of tourniquets to control hemorrhage has been documented as early as the 17th century Advances and uses of tourniquets described by Joseph Lister and Harvey Cushing (among others)
  • 18. Tourniquets Use became discouraged afterWWI following attention to complications (nerve damage, amputations, etc.) More recent experience in Middle East conflicts has suggested a benefit with selected use  2006 Kragh et. al. prospective study from Baghdad. 90% vs. 10% survival rate among tourniquet use in the presence of shock; 11% vs. 24% mortality for tourniquets placed in the field compared to ER.
  • 19. Extremity GSWs in the ER- Priorities • Overall patient condition (identification and treatment of shock) • Identification of vascular injuries/control of hemorrhage • Identification of orthopedic injuries • Identification of nervous injuries • Management of soft tissue injuries
  • 20. “Hard Signs” ofVascular Injury Active/pulsatile hemorrhage Expanding hematoma Pulse deficit Palpable thrill/bruit
  • 21. “Soft Signs” ofVascular Injury Hematoma History of significant blood loss Proximity to major vessels  Incidence of arterial injury is 2-25%
  • 22. Arterial Pressure Index (API) Blood pressure ratio of lower to upper extremity > 0.9 considered normal Caution if pre-existing PVD
  • 23. Physical ExamPhysical Exam Hard Signs?Hard Signs? Yes No OR for Exploration OR for Exploration Soft Signs?Soft Signs? Yes No APIAPI < 0.9< 0.9 Imaging (CTA)Imaging (CTA) ObservationObservation NoYes Injury?Injury? Yes No
  • 24. Complex ExtremityTrauma Combined soft tissue, osseous, vascular/nerve injuries More common with high energy weaponry (assault rifles, etc. ) or close range shotgun wounds
  • 25. Risk Factors for Amputation Gustilo III-C injuries Prolonged ischemia (>4-6 hours) Destructive soft tissue injury Multiple/severely comminuted fractures/segmental bone loss Old age/severe comorbidity Lower vs. upper extremity Failed revascularization
  • 26. Vascular Shunting Definitive vascular repair takes time  Temporary solution to restore flow Indications:  HD instability/coagulopathy/acidosis/hypothermia  Unstable skeleton  Major wound contamination/infection or soft tissue deficit  Austere environment  Poly-trauma with other life threatening injuries
  • 27. Nerve Related Injuries May be caused by concussion zone of blast injury (neuropraxic/contusion injuries)  Will recover spontaneously Progressive deficits may indicate an expanding hematoma or pseudoaneurysm  Decompression/resection can reverse deficit
  • 28. Nerve Related Injuries Delayed operative intervention for neurologic deficit most often favored  Allows time for spontaneous recovery of contusion injuries  Allows determination of the the full extent of injury (prevents inadequate debridement)  Surrounding contusion can lead to epineural softening and suture failure
  • 29. Nerve Related Injuries If early exploration is indicated for other reasons (i.e. vascular), nerve exploration is warranted in stable patients with deficits  Primary repair for clean/sharp transections (rare with GSWs)  Nerve ends can be tacked to fascia to prevent retraction  Ends tagged or clipped for later identification
  • 30. Case #1 24 year old man “Minding his own business” when shot in the right upper ext HD stable Single GSW outer mid portion of upper arm Clear radial pulse deficit Grossly neurologically intact
  • 31. Case #2 41 year old man shot during attempted robbery HD stable 2 GSWs anterior/posterior right upper thigh (presumed entrace/exit) Palpable left pedal pulses; Dopplerable right pedal pulses; ABI 0.2