Penetrating trauma in Netherlands Antilles? No difference! Jeannouel van Leeuwen MD Trauma in the Caribbean II  November 6...
Woundman, from  Hans von Gersdorff,  Feldtbuch der Wundartzney , 1517.
Epidemiology of  Penetrating Trauma <ul><li>In 2002 firearms caused 30,242 deaths for a rate of 10.5 per 100,000 residents...
Physics of  Penetrating Trauma <ul><li>Recall Kinetic Energy Equation </li></ul><ul><ul><li>Greater the mass the greater t...
Physics of  Penetrating Trauma <ul><li>Remainder of energy propels bullet forward at a high rate of speed. </li></ul><ul><...
A Lesson From Einstein <ul><li>Energy cannot be created or destroyed </li></ul><ul><li>Force has to go somewhere </li></ul...
Mechanisms of Injury in Penetrating Trauma <ul><li>Low velocity injuries  </li></ul><ul><ul><li>Knife wounds </li></ul></u...
<ul><li>Type of weapon involved. </li></ul><ul><li>Path of weapon. </li></ul><ul><li>Depth of penetration. </li></ul><ul><...
High-Energy Penetrating Injuries How do these weapons differ from handguns and shotguns? How do the wounds differ internal...
Medium-Energy Penetrating Injuries
Low-Energy Penetrating Wounds How does the length of the weapon relate to the cone of damage?
Low-Energy Injuries <ul><li>Low velocity. </li></ul><ul><li>Usually hand-driven weapons. </li></ul><ul><li>Less secondary ...
 
Damage Pathway <ul><li>Direct Injury </li></ul><ul><ul><li>Damage done as the projectile strikes tissue </li></ul></ul><ul...
 
Damage Pathway <ul><li>Projectile Injury Process </li></ul><ul><ul><li>Tip impacts tissue </li></ul></ul><ul><ul><li>Tissu...
Projectiles <ul><li>Different types of projectiles will cause different types of wounds </li></ul>Every bullet tells a story
Wound Characteristics <ul><li>Entrance Wounds </li></ul><ul><ul><li>Size of bullet profile for non-deforming bullets </li>...
General Body Regions <ul><li>Neck </li></ul><ul><ul><li>Damages Trachea and Blood Vessels </li></ul></ul><ul><ul><li>Neuro...
Specific Tissue &  Organ Injuries <ul><li>Lungs </li></ul><ul><ul><li>Air in lung absorbs energy </li></ul></ul><ul><ul><l...
Now go and treat soft tissue injuries…. Reason #1 why you’re supposed to wear a helmet!
Head Trauma Boy, it almost feels like I’ve been shot with an arrow.
Head Trauma Yup, that definitely feels like an arrow .
Transmediastinal Chest Wounds <ul><li>The area bordered by the sternum, spine, and lungs which includes the trachea, aorta...
Penetrating Chest Trauma <ul><li>Location, location!!! </li></ul><ul><ul><li>Transmediastinal </li></ul></ul><ul><ul><li>C...
General Body Regions <ul><li>Extremities </li></ul><ul><ul><li>Injury limited to resiliency of tissue </li></ul></ul><ul><...
Evaluation and Management <ul><li>Thoracotomy or clam-shell thoracotomy necessary if loss of vital signs </li></ul><ul><li...
Penetrating Chest Trauma <ul><li>Accounts for 20-25% of trauma related deaths </li></ul><ul><li>16,000 US deaths a year du...
Special Concerns with Penetrating Trauma <ul><li>Penetrating Wound Care </li></ul><ul><ul><li>Facial Wounds </li></ul></ul...
Pericardial Effusion
Peripheral Thoracic Injuries <ul><li>Normal initial chest x ray </li></ul><ul><li>6 hour chest xray </li></ul><ul><li>If n...
Anterior Central Wounds <ul><li>Echo to eval for hemopericardium </li></ul><ul><ul><li>Consider repeating in 6 hours for b...
… because we care about the diaphragm! <ul><li>Diaphragm can rise as high as the 4 th  thoracic vertebrae </li></ul><ul><l...
 
FAST Scan <ul><li>Good for identification of pericardial fluid </li></ul><ul><li>Positive fast scan does not tell you whic...
Local Wound Exploration <ul><li>Extend wound and follow the tract </li></ul><ul><li>Penetration of the anterior abdominal ...
Diagnostic Options in Thoracoabdominal Injuries <ul><li>DPL  </li></ul><ul><li>CT – low sensitivity in diaphragm injuries,...
Serial Physical Exams <ul><li>24 hour obs </li></ul><ul><li>Hourly physical exams by same person </li></ul><ul><li>Checkin...
Flank or Back Stab Wounds <ul><li>INJURIES TO RETROPERITONEAL ORGANS SUCH AS THE COLON, KIDNEY AND LUMBAR VESSELS - OR MOR...
Diagnostic Options <ul><li>Serial Physical Examination (PE)  </li></ul><ul><li>Local Wound Exploration (LWE)  </li></ul><u...
 
Stable Patients <ul><li>Evaluate for injury – “A tube or finger in every orifice!” </li></ul><ul><ul><li>Chest Xray </li><...
Unstable Patients <ul><li>Need to go to OR </li></ul><ul><li>Decide which cavity to open first </li></ul><ul><ul><li>Obvio...
Penetrating Abdominal Trauma <ul><li>abdomen extends from the nipples to the groin crease anteriorly, and the tips of the ...
Abdominal Injuries:  Evisceration <ul><ul><li>Definition:  </li></ul></ul><ul><ul><ul><li>Organs protruding through wound ...
It is better to see the outside of the artery before you see the inside
Pulseless Penetrating Abdominal Trauma <ul><li>Major vascular injury has occurred </li></ul><ul><li>Patient has loss of vi...
Pulseless Penetrating Abdominal Trauma Surgical complications are more likely on public holidays
Penetrating Abdominal Trauma Frequent dilemma:take your wife for dinner or the patient back to the OR?
 
Buttock or Perineum Injury <ul><li>Missed rectal injury is dangerous </li></ul><ul><li>Requires proctoscopy and sigmoidosc...
Impalement Treatment <ul><li>Stabilize the victim </li></ul><ul><li>Stabilize the impaled object </li></ul><ul><li>ABC’s <...
Take Home Message – Don’t get shot or stabbed!!!
Upcoming SlideShare
Loading in …5
×

Penetratingtrauma

2,225 views

Published on

0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,225
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
285
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide
  • Too big, too much, not enough time. This is enough to get you started with your own questions. Limits: 330 years, no medieval, no Victorian. Wound Care, Cuts/Stabs, Fractures, Shooting, Skull Fractures no operative surgery: cataracts, bladder stones, hernias, fistulas, bites, tumors, STDs or child birth I am an amateur historian – NOT a medical professional
  • Rate of penetrating trauma is dependent on city/gangs/etc
  • pneumoperitoneum
  • Why wouldn’t you go straight to belly
  • Penetratingtrauma

    1. 1. Penetrating trauma in Netherlands Antilles? No difference! Jeannouel van Leeuwen MD Trauma in the Caribbean II November 6-8, 2009
    2. 2. Woundman, from Hans von Gersdorff, Feldtbuch der Wundartzney , 1517.
    3. 3. Epidemiology of Penetrating Trauma <ul><li>In 2002 firearms caused 30,242 deaths for a rate of 10.5 per 100,000 residents </li></ul><ul><li>Rate of penetrating trauma is 20% in the US </li></ul>Surgery is the most dangerous activity in legal society
    4. 4. Physics of Penetrating Trauma <ul><li>Recall Kinetic Energy Equation </li></ul><ul><ul><li>Greater the mass the greater the energy </li></ul></ul><ul><ul><ul><li>Double mass = double KE </li></ul></ul></ul><ul><ul><li>Greater the speed the greater the energy </li></ul></ul><ul><ul><ul><li>Double speed = 4x increase KE </li></ul></ul></ul>
    5. 5. Physics of Penetrating Trauma <ul><li>Remainder of energy propels bullet forward at a high rate of speed. </li></ul><ul><li>Trajectory is curved due to gravity </li></ul><ul><li>As bullet strikes object, it slows and energy is transferred to object. </li></ul><ul><ul><li>Law of Conservation of Energy </li></ul></ul>Surgery is a controlled trauma under anaesthesia
    6. 6. A Lesson From Einstein <ul><li>Energy cannot be created or destroyed </li></ul><ul><li>Force has to go somewhere </li></ul><ul><li>Energy is transmitted through human tissue </li></ul><ul><li>Newton’s Law of Physics </li></ul><ul><li>Force= Change in Velocity x Mass </li></ul>Everything should be made as simple as possible , but not simpler
    7. 7. Mechanisms of Injury in Penetrating Trauma <ul><li>Low velocity injuries </li></ul><ul><ul><li>Knife wounds </li></ul></ul><ul><ul><li>Disrupt only the structures penetrated </li></ul></ul><ul><li>Medium velocity injuries </li></ul><ul><ul><li>Handguns and pellet guns </li></ul></ul><ul><li>High Velocity Injuries </li></ul><ul><ul><li>Military weapons and rifles </li></ul></ul><ul><li>Shotgun injuries are usually considered medium velocity but tend to cause a large amount of injury due to transmitted kinetic energy </li></ul>
    8. 8. <ul><li>Type of weapon involved. </li></ul><ul><li>Path of weapon. </li></ul><ul><li>Depth of penetration. </li></ul><ul><li>Number of wounds. </li></ul><ul><li>Underlying anatomy. </li></ul>Assessment of Low-Energy Injuries It is easier to stay out of trouble than to get out of it
    9. 9. High-Energy Penetrating Injuries How do these weapons differ from handguns and shotguns? How do the wounds differ internally and externally?
    10. 10. Medium-Energy Penetrating Injuries
    11. 11. Low-Energy Penetrating Wounds How does the length of the weapon relate to the cone of damage?
    12. 12. Low-Energy Injuries <ul><li>Low velocity. </li></ul><ul><li>Usually hand-driven weapons. </li></ul><ul><li>Less secondary trauma. </li></ul><ul><li>Multiple wounds from a single weapon. </li></ul>
    13. 14. Damage Pathway <ul><li>Direct Injury </li></ul><ul><ul><li>Damage done as the projectile strikes tissue </li></ul></ul><ul><li>Pressure Shock Wave </li></ul><ul><ul><li>Human tissue is semi-fluid </li></ul></ul><ul><ul><li>Solid and dense organs are damaged greatly </li></ul></ul><ul><li>Temporary Cavity </li></ul><ul><ul><li>Due to cavitation </li></ul></ul><ul><li>Permanent Cavity </li></ul><ul><ul><li>Due to seriously damaged tissue </li></ul></ul><ul><li>Zone of Injury </li></ul><ul><ul><li>Area that extends beyond the area of permanent injury </li></ul></ul>
    14. 16. Damage Pathway <ul><li>Projectile Injury Process </li></ul><ul><ul><li>Tip impacts tissue </li></ul></ul><ul><ul><li>Tissue pushed forward and to the side </li></ul></ul><ul><ul><li>Tissue collides with adjacent tissue </li></ul></ul><ul><ul><ul><li>Shock wave of pressure forward and lateral </li></ul></ul></ul><ul><ul><ul><ul><li>Moves perpendicular to bullet path </li></ul></ul></ul></ul><ul><ul><li>Rapid compression, crushes and tears tissue </li></ul></ul><ul><ul><li>Cavity forms behind bullet pulling in debris with suction. </li></ul></ul>
    15. 17. Projectiles <ul><li>Different types of projectiles will cause different types of wounds </li></ul>Every bullet tells a story
    16. 18. Wound Characteristics <ul><li>Entrance Wounds </li></ul><ul><ul><li>Size of bullet profile for non-deforming bullets </li></ul></ul><ul><ul><li>Deforming projectiles may cause large wounds </li></ul></ul><ul><ul><li>Close Range </li></ul></ul><ul><ul><ul><li>Powder Burns (Tattooing of powder) </li></ul></ul></ul><ul><ul><ul><li>1-2 mm circle of discoloration </li></ul></ul></ul><ul><ul><ul><li>Localized subcutaneous emphysema </li></ul></ul></ul><ul><li>Exit Wounds </li></ul><ul><ul><li>Appears to be “Blown” outward </li></ul></ul><ul><ul><ul><li>Pressure wave </li></ul></ul></ul>Good judgement comes from experience. Experience comes from poor judgement.
    17. 19. General Body Regions <ul><li>Neck </li></ul><ul><ul><li>Damages Trachea and Blood Vessels </li></ul></ul><ul><ul><li>Neurological problems </li></ul></ul><ul><ul><li>Sucking neck wound </li></ul></ul><ul><li>Head </li></ul><ul><ul><li>Cavitational energy trapped inside skull </li></ul></ul><ul><ul><li>Serious bleeding and lethal </li></ul></ul>
    18. 20. Specific Tissue & Organ Injuries <ul><li>Lungs </li></ul><ul><ul><li>Air in lung absorbs energy </li></ul></ul><ul><ul><li>Parenchyma is compressed and rebounds </li></ul></ul><ul><ul><li>Pneumothorax or hemothorax can result </li></ul></ul><ul><li>Bone </li></ul><ul><ul><li>Resists displacement until it shatters </li></ul></ul><ul><ul><li>Alters projectile path </li></ul></ul>
    19. 21. Now go and treat soft tissue injuries…. Reason #1 why you’re supposed to wear a helmet!
    20. 22. Head Trauma Boy, it almost feels like I’ve been shot with an arrow.
    21. 23. Head Trauma Yup, that definitely feels like an arrow .
    22. 24. Transmediastinal Chest Wounds <ul><li>The area bordered by the sternum, spine, and lungs which includes the trachea, aorta, vena cava, heart, and esophagus </li></ul><ul><li>Two thirds of these injuries are lethal </li></ul><ul><ul><li>Pericardial tamponade </li></ul></ul><ul><ul><li>Cardiac or great vessel injury </li></ul></ul><ul><ul><li>Esophageal or Transbronchial Injury </li></ul></ul>
    23. 25. Penetrating Chest Trauma <ul><li>Location, location!!! </li></ul><ul><ul><li>Transmediastinal </li></ul></ul><ul><ul><li>Central </li></ul></ul><ul><ul><li>Thoracoabdominal </li></ul></ul><ul><ul><li>Peripheral </li></ul></ul>
    24. 26. General Body Regions <ul><li>Extremities </li></ul><ul><ul><li>Injury limited to resiliency of tissue </li></ul></ul><ul><ul><li>60-80% of injuries with <10% mortality </li></ul></ul><ul><li>Abdomen (Includes Pelvis) </li></ul><ul><ul><li>Highly susceptible to injury and hemorrhage </li></ul></ul><ul><ul><li>Bowel perforation: 12-24 hrs peritoneal irritation </li></ul></ul><ul><li>Thorax </li></ul><ul><ul><li>Rib impact results in explosive energy </li></ul></ul><ul><ul><li>Heart & great vessels have extensive damage due to lack of fluid compression </li></ul></ul><ul><ul><li>Any large chest wound compromises breathing </li></ul></ul>
    25. 27. Evaluation and Management <ul><li>Thoracotomy or clam-shell thoracotomy necessary if loss of vital signs </li></ul><ul><li>Echocardiography </li></ul><ul><li>Aortography or CT angiogram </li></ul><ul><li>Bronchoscopy to eval tracheobronchial injuries </li></ul>
    26. 28. Penetrating Chest Trauma <ul><li>Accounts for 20-25% of trauma related deaths </li></ul><ul><li>16,000 US deaths a year due to chest trauma </li></ul>
    27. 29. Special Concerns with Penetrating Trauma <ul><li>Penetrating Wound Care </li></ul><ul><ul><li>Facial Wounds </li></ul></ul><ul><ul><ul><li>Difficult intubations </li></ul></ul></ul><ul><ul><ul><ul><li>Depress chest </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pass ET through bubbling tissue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Consider Cricothyroidotomy </li></ul></ul></ul></ul><ul><li>Chest Wounds </li></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><ul><li>2/3” the diameter of the trachea or larger to entrain air </li></ul></ul></ul><ul><ul><ul><li>3-sided occlusive dressing </li></ul></ul></ul><ul><ul><ul><li>Needle Decompress </li></ul></ul></ul><ul><ul><li>Pericardial Tamponade </li></ul></ul>
    28. 30. Pericardial Effusion
    29. 31. Peripheral Thoracic Injuries <ul><li>Normal initial chest x ray </li></ul><ul><li>6 hour chest xray </li></ul><ul><li>If negative, patient can be discharged </li></ul><ul><li>These patients need angiography if: </li></ul><ul><ul><li>Supraclavicular or axillary hematoma </li></ul></ul><ul><ul><li>Ongoing bleeding </li></ul></ul><ul><ul><li>Pulse deficit in extremities </li></ul></ul><ul><ul><li>Apical hematoma on CXR </li></ul></ul>
    30. 32. Anterior Central Wounds <ul><li>Echo to eval for hemopericardium </li></ul><ul><ul><li>Consider repeating in 6 hours for best sensitivity </li></ul></ul><ul><ul><li>Or consider CT chest </li></ul></ul>
    31. 33. … because we care about the diaphragm! <ul><li>Diaphragm can rise as high as the 4 th thoracic vertebrae </li></ul><ul><li>Diaphragmatic injury occurs in </li></ul><ul><ul><li>45% of thoracoabdominal GSWs </li></ul></ul><ul><ul><li>15% of thoracoabdominal stab wounds </li></ul></ul><ul><li>Injuries are more common on the left </li></ul>
    32. 35. FAST Scan <ul><li>Good for identification of pericardial fluid </li></ul><ul><li>Positive fast scan does not tell you which organ is injured </li></ul><ul><li>Negative fast scan does not exclude injury </li></ul>
    33. 36. Local Wound Exploration <ul><li>Extend wound and follow the tract </li></ul><ul><li>Penetration of the anterior abdominal fascia is considered positive and patient gets laparotomy </li></ul><ul><li>25% of anterior abdominal stab wounds do not penetrate </li></ul><ul><li>Only 50% that do penetrate actually require surgical intervention </li></ul>
    34. 37. Diagnostic Options in Thoracoabdominal Injuries <ul><li>DPL </li></ul><ul><li>CT – low sensitivity in diaphragm injuries, but defines solid organ injuries </li></ul><ul><li>Ultrasound </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Thoracoscopy </li></ul>
    35. 38. Serial Physical Exams <ul><li>24 hour obs </li></ul><ul><li>Hourly physical exams by same person </li></ul><ul><li>Checking for hemodynamic instability or development of peritonitis </li></ul><ul><li>Sensitive for injury but has disadvantages of time, money </li></ul>
    36. 39. Flank or Back Stab Wounds <ul><li>INJURIES TO RETROPERITONEAL ORGANS SUCH AS THE COLON, KIDNEY AND LUMBAR VESSELS - OR MORE RARELY THE PANCREAS, AORTA AND INFERIOR VENA CAVA </li></ul><ul><li>COLON IS THE INJURY MOST OFTEN MISSED </li></ul><ul><li>CT SCAN. WHERE THE WOUND TRACK EXTENDS UP TO THE COLON, OR THERE IS EVIDENCE OF ABNORMAL BOWEL WALL THICKENING, LAPAROTOMY IS INDICATED </li></ul>
    37. 40. Diagnostic Options <ul><li>Serial Physical Examination (PE) </li></ul><ul><li>Local Wound Exploration (LWE) </li></ul><ul><li>Diagnostic Peritoneal Lavage (DPL) </li></ul><ul><li>Ultrasound (FAST) </li></ul><ul><li>CT Scan </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Laparotomy </li></ul>If you see two surgeons laughing, someone is in trouble
    38. 42. Stable Patients <ul><li>Evaluate for injury – “A tube or finger in every orifice!” </li></ul><ul><ul><li>Chest Xray </li></ul></ul><ul><ul><li>NG Tube </li></ul></ul><ul><ul><li>Urinary Catheter </li></ul></ul><ul><ul><li>Rectal Exam/Vaginal Exam </li></ul></ul><ul><li>If signs of peritonitis – then to OR! </li></ul>
    39. 43. Unstable Patients <ul><li>Need to go to OR </li></ul><ul><li>Decide which cavity to open first </li></ul><ul><ul><li>Obvious penetrating injury to abdomen requires laparotomy </li></ul></ul><ul><ul><li>Questions may arise if multiple area penetrating trauma, massive hemothorax, evidence of tamponade, “grey zone areas” such as thoracoabdominal junction, buttock wound </li></ul></ul><ul><ul><li>Sometimes need diagnostic testing </li></ul></ul><ul><ul><ul><li>Diagnostic Peritoneal Lavage </li></ul></ul></ul><ul><ul><ul><li>FAST Scan </li></ul></ul></ul><ul><ul><ul><li>Beware of CT in unstable patients </li></ul></ul></ul>
    40. 44. Penetrating Abdominal Trauma <ul><li>abdomen extends from the nipples to the groin crease anteriorly, and the tips of the scapulae to the gluteal skin crease inferiorly. </li></ul>
    41. 45. Abdominal Injuries: Evisceration <ul><ul><li>Definition: </li></ul></ul><ul><ul><ul><li>Organs protruding through wound </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>DO NOT TOUCH OR REPLACE the organ </li></ul></ul></ul><ul><ul><ul><li>Cover with a sterile dressing moistened with sterile water </li></ul></ul></ul><ul><ul><ul><li>Cover with a dry sterile dressing and tape in place </li></ul></ul></ul><ul><ul><ul><li>Cover with plastic wrap </li></ul></ul></ul><ul><ul><ul><li>Tape completely around the border of the dressing </li></ul></ul></ul><ul><ul><ul><li>Flex the pts hips and knees, if uninjured </li></ul></ul></ul>
    42. 46. It is better to see the outside of the artery before you see the inside
    43. 47. Pulseless Penetrating Abdominal Trauma <ul><li>Major vascular injury has occurred </li></ul><ul><li>Patient has loss of vital signs </li></ul><ul><li>Need immediate laparotomy (i.e. within 5 minutes of arrival) or ED thoracotomy with aortic cross clamping </li></ul><ul><li>Eviscerate and go for the bleeder </li></ul>The lowest mortality and fewest complications result from the removal of normal tissue
    44. 48. Pulseless Penetrating Abdominal Trauma Surgical complications are more likely on public holidays
    45. 49. Penetrating Abdominal Trauma Frequent dilemma:take your wife for dinner or the patient back to the OR?
    46. 51. Buttock or Perineum Injury <ul><li>Missed rectal injury is dangerous </li></ul><ul><li>Requires proctoscopy and sigmoidoscopy </li></ul>
    47. 52. Impalement Treatment <ul><li>Stabilize the victim </li></ul><ul><li>Stabilize the impaled object </li></ul><ul><li>ABC’s </li></ul><ul><li>Advanced life support (IV, decompression, etc.) </li></ul><ul><li>DO NOT REMOVE THE OBJECT </li></ul>
    48. 53. Take Home Message – Don’t get shot or stabbed!!!

    ×