Objectives
Discuss some basic principles of ballistics and tissue injury
Review basic management principles for extremit...
Factors inTissue Injury
K = mv2
2E K= Kinetic
Energy
m= mass
V= velocity
Caliber
Inside diameter of the barrel of the gun
 Expressed in hundredths of inches
 Ex:
 .38 caliber
 .22 caliber
Caliber Matters?
12 G .45 .38 .32 .22
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)
Cavitation
Formation and then immediate implosion of cavities in
a liquid that are the consequence of forces acting upon
t...
Fackler ML.Ballistic injury. Ann Emerg
Med. 1986 Dec;15(12):1451-5
Fragmentation
Tissue injury also proportional to the cross sectional area
of the missile
.38
Fackler ML.Ballistic
injury. Ann Emerg
Med. 1986
Dec;15(12):1451-5
.357
Fackler ML.Ballistic injury.
Ann Emerg Med. 1986
Dec;15(12):1451-5
.22 Long Rifle
.306 Long Rifle
12 G Shotgun
Management of gunshot
wounds to the extremities
Hemorrhage Control in the Field
Direct pressure or compression dressings preferred and
often successful
Avoid “clamping”...
Tourniquets
Tourniquets
Use of tourniquets to control hemorrhage has been
documented as early as the 17th
century
Advances and uses ...
Tourniquets
Use became discouraged afterWWI following attention to
complications (nerve damage, amputations, etc.)
More ...
Extremity GSWs in the ER- Priorities
• Overall patient condition (identification and treatment of shock)
• Identification ...
“Hard Signs” ofVascular Injury
Active/pulsatile hemorrhage
Expanding hematoma
Pulse deficit
Palpable thrill/bruit
“Soft Signs” ofVascular Injury
Hematoma
History of significant blood loss
Proximity to major vessels
 Incidence of art...
Arterial Pressure Index (API)
Blood pressure ratio of lower to upper extremity
> 0.9 considered normal
Caution if pre-e...
Physical ExamPhysical Exam
Hard Signs?Hard Signs?
Yes No
OR for
Exploration
OR for
Exploration
Soft Signs?Soft Signs?
Yes ...
Complex ExtremityTrauma
Combined soft tissue, osseous, vascular/nerve injuries
More common with high energy weaponry (as...
Risk Factors for Amputation
Gustilo III-C injuries
Prolonged ischemia (>4-6 hours)
Destructive soft tissue injury
Mult...
Vascular Shunting
Definitive vascular repair takes time
 Temporary solution to restore flow
Indications:
 HD instabili...
Nerve Related Injuries
May be caused by concussion zone of blast injury
(neuropraxic/contusion injuries)
 Will recover s...
Nerve Related Injuries
Delayed operative intervention for neurologic deficit most
often favored
 Allows time for spontan...
Nerve Related Injuries
If early exploration is indicated for other reasons (i.e.
vascular), nerve exploration is warrante...
Case #1
24 year old man
“Minding his own business” when shot in the right upper
ext
HD stable
Single GSW outer mid por...
Case #2
41 year old man shot during attempted robbery
HD stable
2 GSWs anterior/posterior right upper thigh (presumed
e...
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes
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Day 2 | CME- Trauma Symposium | Gunshots to extremeties bennes

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

    1. 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. 2. Factors inTissue Injury K = mv2 2E K= Kinetic Energy m= mass V= velocity
    3. 3. Caliber Inside diameter of the barrel of the gun  Expressed in hundredths of inches  Ex:  .38 caliber  .22 caliber
    4. 4. Caliber Matters? 12 G .45 .38 .32 .22
    5. 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. 6. Cavitation Formation and then immediate implosion of cavities in a liquid that are the consequence of forces acting upon the liquid.
    7. 7. Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
    8. 8. Fragmentation Tissue injury also proportional to the cross sectional area of the missile
    9. 9. .38 Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
    10. 10. .357 Fackler ML.Ballistic injury. Ann Emerg Med. 1986 Dec;15(12):1451-5
    11. 11. .22 Long Rifle
    12. 12. .306 Long Rifle
    13. 13. 12 G Shotgun
    14. 14. Management of gunshot wounds to the extremities
    15. 15. Hemorrhage Control in the Field Direct pressure or compression dressings preferred and often successful Avoid “clamping” Consider the use of a tourniquet
    16. 16. Tourniquets
    17. 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. 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. 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. 20. “Hard Signs” ofVascular Injury Active/pulsatile hemorrhage Expanding hematoma Pulse deficit Palpable thrill/bruit
    21. 21. “Soft Signs” ofVascular Injury Hematoma History of significant blood loss Proximity to major vessels  Incidence of arterial injury is 2-25%
    22. 22. Arterial Pressure Index (API) Blood pressure ratio of lower to upper extremity > 0.9 considered normal Caution if pre-existing PVD
    23. 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. 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. 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. 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. 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. 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. 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. 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. 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

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