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Ballistics in Trauma
- 1. Holistic BallisticsHolistic Ballistics Bullet Physics and Traumatic InjuriesBullet Physics and Traumatic Injuries Matthew Esposito, MS IV Dr. Dene W. Daugherty
- 2. Overview • Introduction • Ballistic Physics (hang in there) • Physical Exam • GSW Workup and Management – Head – Neck – Thorax – Abdomen – GU – Extremities
- 3. Introduction • 2007 CDC statistics – 69,863 (est.) injuries – 31,000 deaths • 40.5% Homicide • 55% Suicide – GSWs were more common in men, African Americans were 2x likely to suffer fatal injuries than Caucasian
- 4. Introduction
- 5. Introduction • Small Arms – Handguns, Shotguns and Rifles – Rifles: high pressure (50K PSI) & velocity (> 2000f/s) – Handguns: modest pressure (30K PSI) & velocity (< 2000 f/s) – Shotguns: low pressures, large expansion • Heavy Arms - machine guns, grenade launchers, mortars, shoulder-launched missile weapons, • Hollow Point vs. FMJ vs. Shot – FMJ: Wounding – HP: Killing – Shot: Spread
- 6. Physics
- 7. Physics 101
- 8. Physics• Ballistic Gelatin (1940s) – validated tissue surrogate – Does not account for different tissue densities – bone, muscle, skin
- 9. Physics • 3 Components – Internal: Path of the projectile in the gun – External: Path from the muzzle to target • gravity and air resistance – Terminal: Path inside target • Permanent Cavity: Depends on caliber of ball • Temporary Cavity: Depends on velocity of ball, can be 10-30x size of permanent cavity – Secondary Wounding: Newton’s 1st Law
- 10. Physical Exam • MARCHs vs. ABCDE • Vital Signs & GCS • Rapid Physical Assessment – DCAP BTLS – Location and Number of entry and exit wounds • Hard vs. Soft Signs • SAMPLE History
- 11. Head Injuries • Zafonte et al: – 36% of patients dead on arrival to the ED or expired in the ED, 77% overall mortality in first 48hrs • Eastern Association for the Surgery of Trauma – Introduced first set of guidelines for care of penetrating brain injury in 2001 • Fluid Resuscitation: Albumen vs. Synthetic Colloid vs. Hypertonic Saline • Imaging: – Non-contrast CT • Antibiotics: – Prophylaxis with Ceftriaxone +/- Metronidazole and Vancomycin • Antiepleptics: – Phenytoin • ICP Control: – Mannitol vs. Hypertonic Saline (3-23.4%) – Head of bed > 30° – No more Hyperventillation
- 13. Neck Injuries • ABCs, ATLS, Physical Examination of Wound • Platysma violation is an indication for operative evaluation and observation for at least 24 hours. • Airway Management: RSI and ETT with surgical backup • Evaluation: Unstable Patient OR, Stable Patient Imaging – Zones 1, 3: Require additional imaging in a stable patient – Zone 2: Selective operative management • Imaging: Angiography, CTA, duplex ultrasonography, direct visualization or esophagogram • CT with angiography should be obtained to evaluate for vascular or aerodigsestive track injuries in stable patients
- 14. Neck Injuries
- 15. Thoracic Injuries • Major vascular injuries occur in 4% of penetrating chest trauma, if tracheobronchial injuries are present, the proportion of patients with major vascular injuries increases to 30%. Many don’t survive to the ED • Imaging: – E-FAST: Look for pericardial effusion, hemoperitoneum, pneumothorax, and hemothorax – CXR: Required in all thoracic GSW – CT: Hemodynamically stable patients, find occult injuries • Treatment: Surgery is often the final common pathway – Thoracotomy, Needle Decompression & Tube Thoracostomy – Fluid Resuscitation (crystalloid, PRBC + FFP 1:1, TXA) – Antibiotic PPX
- 17. Abdominal Injuries • Hollow-organ injuries are the most common (small bowel) • CT and Ultrasound have relegated DPL to an infrequent procedure – Still useful in an unstable patient who cant be transported to CT • Treatment: – Fluid Resuscitation – Unstable: Hemorrhage Control and Exploratory Laparotomy – Stable: Serial Abdominal Exams, Laboratory Values, Imaging – Interventional Radiology – Diagnostic Laparoscopy
- 19. GU Injuries • Only 10% of trauma patients have GU injuries and only 15% of that subset have penetrating trauma • Few life threatening injuries except for kidney or major lacerations to renal vasculature • Majority of injuries are to the external genitalia • Examination: – Look for blood at meatus and gross hematuria – Retrograde urethrogram or CT cystogram
- 20. Extremity Injuries• Considerations: – Vascular and Nerve Injuries – APIs – Compartment Syndrome – Fractures – Nerve Impairment – Joint Injuries • Evaluation: – CTA vs. Angiography vs. Duplex Ultrasonography – Serial Compartment Checks
- 22. Review • Count the number of holes • Pan-Scan • Bullets are not sterile • Blood + FFP (1:1)
- 23. References Firearm Injury Center at Penn “Firearm Injury in the US” Bruner D., Gustafson C., Visintainer C., “Ballistic Injuries in the Emergency Department” Emergency Medicine Practice December 2011 Volume 13 Number 12 Hollerman JJ, Fackler ML. Wound Ballistics. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. Ong RC, Mulvaney SW. Military Medicine. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. Fackler ML. Wound Ballistics: A Review of Common Misconceptions. JAMA. 1988;259(18):2730-2736. doi:10.1001/jama.1988.03720180056033.
Editor's Notes
- Spalling Tumbling and Yaw and bone fragmens
- MARCH – Massive Hemorrhage Control, Airway, Respirations, Circulation, Head Injury, Hemorrhage, Hypothermia, Hydration Deformity, Contusion, Abrasion, Punctures, Burns, Tenderness, Lacerations, Swelling SAMPLE – Signs/Symptoms, Allergies, Medications, Past Medical / Surgical, Last Oral, Events Prior to Arrival Hard Signs – Active hemorrhage, expanding hematoma, pulse deficit, bruit or thrill Soft Signs – Nonpulsatile hematoma, Nervous system ischemia, proximity to major vessel
- Synthetic Colloid – good experimental data supports this but no RCT Hypertonic Saline – Benefits include lower fluid volumes, limited edema formation and reduced inflammation --- HOWEVER no current large trials exist that show a survival benefit compared to conventional trauma resuscitation Imaging: Cranial xray is not recommended, MRI for obvious resions Antibiotics: NO RCT comparing use vs. no use, comparison of infection rates from preantibiotic era suggests antibiotics are effective. Military has used since 1946. No current guidelines for antibiotic choice in penetrating injury, Esposito et al from 2009 Neurosurgery recommends IV Ceftriaxone, Metronidazole and vancomycin Antiepileptics: prophylaxis is still controversial, no good studies comparing new generation AEDs (i.e. kepra) to phenytoin ICP: Mannitol Vialet et all 2003 Critical Care Med – 7.5% saline compared to 20% mannitol, had fewer episodes of ICHypertension, and lower failure rates, low power 20 pts. No recommendations on dosage or concentration. Vialet study suggests 2mg/kg of 7.5%
- Level of Evidence: Always acceptable and safe, proven in both efficacy and effectiveness, one or more large prospective studies are present, high quality meta-analysis, studies are constantly positive and compelling Safe and acceptable, generally higher levels of evidence, non-randomized or retrospective studies: historic, cohort, or case control series, less robust RCTs, results are consistently positive May be acceptable, consider optional or alternative treatment, generally lower or intermediate levels of evidence, case series animal studies or consensus panels, occasionally positive results
- Airway: RSI is safe and effective but neck injuries are always variable and require a second intubation method be present due to the paralytic component of RSI and the need for a crash surgical airway. Crych (needle or tube). Possible complications include transection due to trachial injury Angiography is time and labor intensive but can be diagnostic and therapeutic, CTA can provide information regarding the trajectory of the projectile and reduce the need for neck explorations without increase in mortality risk
- Indications for Thoracotomy: loss of vital signs in the ED, evidence of cardica tamponade, massive hemothorax. Should not be performed if there are no definitive surgical resources available. Needle Decompression: Indicated in the presence of a clinically significant pneumothorax or hemothorax --- only a stabilizing procedure, many fail to enter pleural space 48% --- can insert in 2nd intercostal at midclavicular or 4/5th at midaxillary Fluid Recussitation: literature supports the role of permissive hypotension in penetrating trauma to reduce the possibility of causing increased hemorrhage by dislodging a clot or tamponade that has occurred naturally. Sanabria et all performed metaanalysis on 5 RCTs and found that patients given PPX had decreased frequency of pneumonia and posttraumatic empyema
- Hemorrhage – control with direct pressure, pressure binders, fluid resuscitation and blood Labs – CBC, ABG, CMP, Lactate, Urinalysis, Type and Cross Indications for surgery – Significant base deficit, high lactate levels and significant anemia Radiology – FAST, Plain film for missle location, CT
- Delay foley placement if urethral injury is suspected Must treat life threatening injuries before GU injuries Dye in CT cysto must be delayed 10 minutes
- Handguns account for the majority of extremity injuries in the civilian population, high velocity wounds and shotguns have the greatest potential for devastating injury due to kinetic energy transfer Most commonly injured vessel is the superficial femoral artery, followed by the popliteal artery then the common femoral artery APIs - The arterial pressure index is useful in detecting patients with major vascular injury and pulses that appear normal. Systolic blood pressure in the affected extremity is divided by systolic pressure in the contralateral normal extremity. A value of less than 90% is considered abnormal. Fascial separations play a critical role in injury patterns by acting as a conduit for kinetic energy transfer and injury patterns leading to compartment syndrome The majority of compartment syndromes are found in tibial trauma (blunt and penetrating) Amputations from penetrating trauma is 5.1% and most frequently associated with popliteal artery injury If the injury is neuropraxic (nerve remains intact but nonfunction) or axonometric (axon alone is severed) these patients usually regain function, 70% of documented peripheral nerve injury make a complete recovery Joints and long bones should be placed in anatomical positioning and splinted Description of injury using NOLARD – neurovascular, open vs. closed, location, angulation/alignment, rotation and displacement