Gunshot injuries to the face can cause significant damage and require complex treatment. Immediate management of gunshot wounds to the head and neck follows ATLS protocols to secure the airway, control hemorrhage, and give fluid resuscitation. Further treatment involves thorough debridement and irrigation, stabilization of fractures, and reconstruction of soft tissue and bone defects. Multiple surgeries may be needed for reconstruction, rehabilitation, and to address any residual deformities or functional issues. Long-term follow up is important to monitor healing and manage any complications.

1. Gunshot Injuries to Max-Fac Region
Dr. Khadim Shah
T.M.O

2. • Management of gunshot injuries to the face led in many
ways to the development of modern maxillofacial
surgery, and it remains a cornerstone of the specialty of
oral and maxillofacial surgery.

3. Firearm injuries

4. Firearm injuries

5. Firearm injuries

6. Firearm injuries

7. Handguns
87%
Shotguns
8%
Rifles
5%
0%
Civilian Injuries
Handguns Shotguns Rifles

8. 26%
14%
13%
9%
0%
5%
10%
15%
20%
25%
30%
Multiple Sites Maxilla Mandible Orbit
Sites Involved

9. Ballistics
Ballistics is the science of projectile motion.
• deal with the flight, behavior, and effects of
projectiles
Ballistic science is typically divided into three stages:
Internal Ballistic
External Ballistic
Terminal Ballistic

10. Ballistics
Internal Ballistics

11. Ballistics
External Ballistics

12. Ballistics
Terminal Ballistics

13. Classification of Gunshot Injuries
Low velocity
• ( < 350 m/s )
Intermediate velocity
• (350–600 m/s)
High velocity
• (> 600 m/s)

14. Classification of Gunshot Injuries
Gugala and Lindsey Classification
• Energy
• Involvement of vital structures
• Wound type
• Fracture and
• Contamination

15. Handguns

16. Handguns

17. Rifles

18. Rifles

19. Types of MissileWound
•Non-penetrating:
•Penetrating:
•Perforating:
•Avulsive:

20. •Non-penetrating
• grazing or blast
wound
Types of MissileWound

21. •Penetrating:
•low impact velocity,
bullet does not exit
Types of MissileWound

22. •Penetrating:
•low impact velocity,
bullet does not exit
Types of MissileWound

23. Types of MissileWound
•Penetrating:
•low impact velocity,
bullet does not exit

24. •Penetrating:
•low impact velocity,
bullet does not exit
Types of MissileWound

25. •Perforating:
• High velocity , bullet in
and out
Types of MissileWound

26. Types of MissileWound
•Perforating:
• High velocity , bullet in
and out

27. •Avulsive:
•Massive wounds with
avulsion and loss of
tissues
Types of MissileWound

28. Types of MissileWound
•Avulsive:
•Massive wounds with
avulsion and loss of
tissues

29. Mechanism of GSW

30. Mechanism of GSW

31. Management of gunshot wounds :
Late Phase
Soft Tissue and Bone Reconstruction
Intermediate Phase
Diet and
feeding
Oral hygiene
Control of
infection
Immediate Management
Primary survey
(A,B,C,D,E )
Secondary
survey
Primary surgery

32. Airway
•Remove any foreign bodies or
loose teeth.

33. Airway
•Remove any foreign bodies or
loose teeth.
•Head tilt/Chin lift

34. Airway
•Remove any foreign bodies or
loose teeth.
•Head tilt/Chin lift
•Jaw thrust

35. Airway
•Remove any foreign bodies or
loose teeth.
•Head tilt/Chin lift
•Jaw thrust
•EndotrachealTube

36. Airway
•Remove any foreign bodies or
loose teeth.
•Head tilt/Chin lift
•Jaw thrust
•EndotrachealTube
•Upper Airway Bypass

37. Hemorrhage Control
Direct pressure and packing.
Epistaxis control.
Temporary reduction of the fracture.
Thermocoagulation
Ligation

38. Fluid Resuscitation
•Maintain an IV Line
•Infuse Crystalloids 3 ml for every 1 ml Blood loss
•Need for Colloids, FFP, Blood

39. Secondary Survey
Physical Examination:
•Head to toe examination
•Assessing facial soft tissue status
•Sensory disturbances.
•Motor nerve deficits.
•Ocular and orbital injury.
•Oral cavity examination is crucial.

40. Consultation
•Ophthalmology
•Neurosurgery
•ENT
•General Surgery
•Any other as indicated

41. Penetrating injury of the neck
•Zone I ; from the clavicles to the cricoid
cartilage
•Zone II ; from the cricoid cartilage to the
angle of the mandible.
•Zone III ; from the skull base to the angle
of the mandible

42. Investigations
•Conventional Radiographs
•OPG (Orthopantomogram)

43. Investigations
•Conventional Radiographs
•OPG (Orthopantomogram)
•Lateral Cervical Spine

44. Investigations
•Conventional Radiographs
•OPG (Orthopantomogram)
•LateralCervical Spine
•Chest X-ray

45. Investigations
•Conventional Radiographs
•OPG (Orthopantomogram)
•Lateral Cervical Spine
•Chest X-ray
•PA view of Mandible

46. Investigations
•Conventional Radiographs
•OPG (Orthopantomogram)
•Lateral Cervical Spine
•Chest X-ray
•PA view of Mandible
•OMV

47. Investigations
•Advance ImagingTechnique
•3D CT Complex trauma

48. Investigations
•Advance imaging technique
•3D CT Complex trauma
•Barium Swallow/Endoscopy Esophageal injury

49. Investigations
•Advance imaging technique
•3D CT Complex trauma
•Barium Swallow/Endoscopy Esophageal injury
•CT angiography / Angiography Vascular injury

50. Investigations
•Advance imaging technique
•3D CT Complex trauma
•Barium Swallow/Endoscopy Esophageal injury
•CT angiography / Angiography Vascular injury
•Routine Lab Investigations

51. Treatment Planning
•Patient Counselling / Psychological Support
•InformedWritten Consent
•Treatment options with outcome
•Need for multiple surgeries
•Anesthetist Consultation

52. Primary Surgery
A)Debridement of the wound :
Convert a crushed wound into an incised wound
Vigorous irrigation
Small completely detached pieces of bone better to
be removed.
All pieces with any viable soft tissue attachment
should be conserved

53. B)Management of injury to important structures :
Nerves
Microneurosurgical repair or
Tag both ends of nerves with non-resorbable
suture with early secondary repair (3-4 weeks)
Parotid duct and gland
Duct repair over small silicon tube & leave stent
there in place for 4-6 weeks

56. Management of Skin Loss
• If skin loss (< 2 cm) it should be reconstructed by
undermining
•If more ( > 2 cm ) it is managed by :
•Dressing to promote epithelialisation
•Covered by split thickness skin graft
•Local flaps
•Regional flaps
•Free flap

57. Post Operative Care
•Vital Signs Monitoring
•Diet and feeding
•Liquid diet
•Nasogastric tube can be used in extensive injury
•Saliva shield made of acrylic or silicon can be used
• Gastrostomy if long term bypass of the oral cavity is
necessary

58. Post Operative Care
•Oral hygiene
•Mouth wash with antiseptic solution
•Irrigation
•Brushing
•1% hydrocortisone ointment
•Control of infection
•Prophylactic antibiotics
•Early mobilization
(contd)

59. Follow Up
•Both Clinical and Radiographic
•Residual deformity
•Soft tissue
•Hard tissue
•Ocular examination
•Mouth opening

60. Follow Up
•Nutrition and speech
•Psychological status/support
•Management of complications
•Infection
•Malunion or non union
•Malocclusion
•Facial nerve paralysis etc
(contd)

61. Secondary Revision Surgery
•Residual Deformity
•Functional
•Cosmetic
•Trismus
•Flap Debulking
•Scar Revision
•Vestibuloplasty
•Dental Rehabilitation

62. Avulsive Injury
Pre-Operative Primary Surgery Second Surgery

63. Summary
•2nd most common source of death
•ATLS protocol
•Debridement Fracture Stabilization Primary
closure
•Reconstruction
•Rehabilitation

64. References
• http://crss.pk/story/6229/pakistan-conflict-tracker-
monthly-report-may-2014/
• Rowe and williams maxillofacial injuries
• PETERSON'S PRINCIPLES OF ORAL AND
MAXILLOFACIAL SURGERY Second Edition
• Articles from internet

65. THANKYOU