This document discusses the principles of ballistics and tissue injury from gunshot wounds, as well as management of extremity gunshot wounds. It covers how kinetic energy, caliber size, bullet mass and velocity impact tissue damage. Hard and soft signs of vascular injury are outlined. For extremity gunshot wounds in the ER, priorities include identifying vascular injuries, orthopedic injuries, and nervous injuries. Complex trauma with combined injuries carries higher risk of amputation. Vascular shunting can restore blood flow temporarily. Nerve injuries may warrant exploration if deficits persist after contusion injuries have time to recover spontaneously. Two case examples are presented.
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Managing Gunshot Wounds to Extremities
1.
2.
3. Objectives
Discuss some basic principles of ballistics and tissue injury
Review basic management principles for extremity
gunshot wounds
In the field and definitive care
20. Hemorrhage Control in the Field
Direct pressure or compression dressings preferred and
often successful
Avoid “clamping”
Consider the use of a tourniquet
22. 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)
23. 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.
24. 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
26. “Soft Signs” ofVascular Injury
Hematoma
History of significant blood loss
Proximity to major vessels
Incidence of arterial injury is 2-25%
27. Arterial Pressure Index (API)
Blood pressure ratio of lower to upper extremity
> 0.9 considered normal
Caution if pre-existing PVD
28. 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
29. Complex ExtremityTrauma
Combined soft tissue, osseous, vascular/nerve injuries
More common with high energy weaponry (assault rifles,
etc. ) or close range shotgun wounds
30. 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
31. 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
32.
33.
34.
35. 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
36. 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
37. 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
38. 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
39.
40.
41.
42.
43. 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