1. The document discusses the triage and assessment of abdominal trauma. It outlines the principles of trauma management including treating the greatest threat to life first.
2. The primary and secondary surveys are described in detail, covering the assessment of the airway, breathing, circulation, disability, and exposure. Specific injuries to the abdomen like liver and spleen injuries are also discussed.
3. Investigations for abdominal trauma including focused assessment with sonography, diagnostic peritoneal lavage, CT scans, and grades of injuries are provided. The management of positive findings is also summarized.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
PERFORATED PEPTIC ULCER
PERFORATION
DEFINITION
It is the terminology used for perforation of duodenal ulcer or gastric ulcer or stomal ulcer.
Otherwise all clinical features and management are similar.
Perforation is common in duodenal ulcer
Mortality is more in gastric ulcer perforation and perforation in elderly
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
PERFORATED PEPTIC ULCER
PERFORATION
DEFINITION
It is the terminology used for perforation of duodenal ulcer or gastric ulcer or stomal ulcer.
Otherwise all clinical features and management are similar.
Perforation is common in duodenal ulcer
Mortality is more in gastric ulcer perforation and perforation in elderly
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
Polytrauma and multiple traumata are medical terms describing the condition of a person who has been subjected to multiple traumatic injuries. This will be more prevalent in our country
“Trauma” = Injury of one or more systems,that results in excessive bleeding and mayaffect the normal body functioning.
Defined as cellular disruption caused by anexchange with environmental energy that isbeyond the body's resilience.
Establishing the need for a surgical intervention
Confirmation of relevant physical findings and review of the clinical history and laboratory investigations that support the need of surgical intervention
Type of approach- Benefits & Risks of surgical procedure
The incision site- ease of surgery as well as cosmetic considerations
Type of anesthesia
This is a presentation which contains basics of polytrauma management,ATLS, triage, critical decision making skills, application of Glasgow coma scale and complications of different management strategies, if not applied properly.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. TRAUMA
• Trauma is the study of medical problems
associated with physical injury
• The injury is the adverse effect of a physical
force upon a person
• There are variety of forces that can lead to
injury
3. PRINCIPLES OF TRAUMA
MANAGEMENT
– Treat the greatest threat of life first
– Definitive diagnosis is not immediately important.
– Time matters (“golden hour” emphasizes
urgency).
– Do no further harm.
– Assess, intervene, reassess
4. TRIAGE
A process for sorting injured people into groups
based on their need for or likely benefit from
immediate medical treatment.
5.
6.
7. Initially
• 1 assess basic physiology
• 2 assess anatomy of injury
• 3 assess mechanism of injury
• 4 assess special patients or system
considerations
9. PRIMARY SURVEY
To identify life and limb threatening
injuries
Airway with cervical spine protection.
Breathing and Ventilation
Circulation with hemorrhage control
Disability / neurological status
Exposure / environmental control
10. Airway with cervical spine protection
• Brief history: age, gender, mechanism of injury
• Airway with cervical spine control
– Upper airway (above vocal cords) managed
adjunctively with chin lift/jaw thrust,
– suctioning, oral airway, nasopharyngeal airway,
and
– laryngeal mask airway.
– The most common cause of airway obstruction in
the unconscious patient is the tongue.
11. – Lower airway managed definitively with a cuffed
tube in the trachea (orotracheal intubation,
nasotracheal intubation, or surgical airway—
cricothyroidotomy)
– Assume cervical spine injury in patients sustaining
any blunt injury or penetrating injury above the
chest.
17. • Tension pneumothorax (pneumothorax with hypotension)
with needle decompression (second intercostal space, mid-
clavicular line), followed by 32-36 French anterior chest tube
• Simple pneumothorax with 32-36 French anterior chest
tube
• Open pneumothorax with occlusive chest wall dressing and
36 French anterior chest tube
• Massive hemothorax with 36 French posterior chest tubes
en route to operating room
• Simple hemothorax with 36 French posterior chest tube
• Flail chest/severe pulmonary contusion with intubation and
mechanical ventilation
18.
19. Circulation with haemorrhage control
• Treatment of bleeding is to stop it.
• Pressure over bleeding site.
• Look for clinical signs of shock
• 2 wide bore 14 – 16g peripheral lines should
be started
• Resuscitate with crystalloids/colloids
20. Disabiity
• Rapid neurological evaluation using
– A Alert
– V Responds to verbal
stimulus
– P Responds to pain
– U Unresponsive
21. – Brief neurologic exam
• Level of consciousness: Glasgow Coma Scale
• Pupil symmetry and reaction to light
• Lateralizing signs
– Maintain airway, breathing, and circulation to prevent
secondary brain injury.
– Temporize for evidence of increased intracranial
pressure.
• Elevate head of bed.
• Mild hyperventilation to paCO2 = 35
• Mannitol (1 gm/kg)
• Neurosurgical consultation
22.
23. Exposure and environmental control
– Assess temperature.
– Remove all clothing to facilitate access and
examination.
– Maintain normothermia/prevent hypothermia:
warm room, warm fluids, warm blankets
24. Adjuncts to primary survey and
resuscitation
• Blood :CBP,urea
&electrolytes,glucosetoxicology,clotting
screening,cross match
• ECG
• Two wide bore cannule for IVF
• Urinary and gastric catheters
• Radiographs of the cervical spine&chest
25. Radiographs
• AP chest, to assess for tube and line placements, as
well as subclinical hemopneumothoraces
• Pelvis, to assess for pelvic fracture as a source of
hidden bleeding
• Cervical spine, to assess for source of neurogenic
shock. As long as the cervical spine is protected with
immobilization, this radiologic evaluation can be moved
to the secondary survey
26. – Assessment for intraperitoneal injury
• Focused Assessment by Sonography in Trauma (FAST)
–Looks for fluid in 4 areas (hepatorenal,
splenorenal, pelvic, and pericardial spaces)
–Assumes that fluid represents blood and can
detect 200 cc or more
–Can be rapidly repeated for follow-up
–Not designed to find injuries unassociated
with mild to moderate intraperitoneal fluid
loss
27. Secondary survey
– Begins after primary survey & resuscitation have
been completed .It consists of:
Complete medical history
– Head to toe evaluation
– Complete neurological examination
– Radiological evaluation
– Laboratory Studies
– Formulate management plan
28. Medical history
A Allergies
M Medication
P Past illnesses /pregnancy
L Last meal
E Events / Environment
related to injury
29. Mechanism of injury
– Blunt
» Motor vehicle
» Pedestrian
» Fall
» Crush
– Penetrating
» Gunshot
» Shotgun
» Stab
– Environmental
» Burn
» Cold
» Chemical, radiological, biological
– Primary pressure wave (blast)
– Explosions combine all four mechanisms of injury
30. Examination
• Head
– Mental status: GCS
– Scalp
» Lacerations and avulsions
» Open skull fractures
– Eyes
» Visual acuity: the vital sign of the eye
» Pupil size & reactivity
» Globe integrity & foreign body assessment
» Extraocular muscle movement
– Ears
» Pinna
» External auditory canal
» Hemotympanum and tympanic membrane
45. Causes of blunt injury
• Motor vehicle crashes
• Motor cycle crashes
• Vehicle Pedestrian Collision
• Direct blows to Abdomen
• Falls
46. Seat belt injury
• Tear /avulsion of mesentry
• Rupture of small bowel/colon
• Seat belt sign– appearance of transverse
,linear ecchymosis on Anterior
abdominal Abdomen.
• Chance fracture– presence of lumbar
distraction in X-ray.
• Thrombosis of iliac artery or abdominal aorta.
49. Up and forward movement
• In this sequence the body’s forward motion carries it
up and over the steering wheel with the head being
the lead body portion striking the windshield frame
or roof.
• Once impacted head stops movement but torso is still
in movement until the force is absorbed by spine and
transmitted back, through spine ( cervical spine) is the
least protected part in the body
• And injuries can be caused by compression
(lungs,heart) or shearing force due to fixed kidney
tearing at IFC or aorta
55. Auscultation
• Bowel sound if present after a while after the
injury – almost excludes serious injury.
• Bowel sounds if present in the chest –
diaphragmatic rupture.
58. USG abdomen
– Good for solid organs
– Portable
– Fast
– 100 cc detection blood
– No radiation
– No contrast need
– Not seen well: solid parenchymal, retroperitoneal,
diaphragm
– Problem if: obesity, gas
– Less sensitive than DPL for hemoperitoneal
– Operator dependant
59. CECT abdomen
– Able to define organ injury
– Good for retroperitoneal & vertebral column
– Non-invasive
– Not Operator dependant
– Not great for hollow viscus
– Stable patient
– Cost $$$
– Complications: IV or oral contrast
64. – Criteria for Evaluation of Peritoneal Lavage Fluid.
– Positive
– 20 mL gross blood on free aspiration (10 mL in children)
– 100,000 red cells/ L
– 500 white cells/ L (if obtained 3 hours or more after injury)
– 175 units amylase/dL
– Bacteria on Gram-stained smear
– Bile (by inspection or chemical determination of bilirubin
content)
– Food particles
65. • Intermediate :
• pink fluid on free aspiration
• 50,000-100,000 red cells/L in blunt trauma
• 100-500 white cells/L
• 75-175 units amylase/dl
• Negative :
• clear aspirate,100 white cells/L
• 75 units amylase/dl
66. FAST
Initial diagnostic
evaluation
FAST
Focused Assessment
with Sonography for
Trauma
X-ray pelvis and
chest
FAST negative
Diagnostic peritoneal
lavage
Positive DPL and Unstable
Explorative
laprotomy
FAST positive
US abdomen
CT abdomen
FAST negative and unstable
Exploratory laprotomy
67. • Identification of abnormal collection of fluid
or blood.
• Standard FAST, four areas:
• Rt upper quadrant
• Subxiphoid area
• Lt upper quadrant
• Pelvis
68. • The technique focuses on only 4 areas:
pericardial
splenic
hepatic
pelvic
Disadvantages:
• It will not reliably detect less than 100ml of free
blood
• it does not identify injury to hollow viscus
• It cannot reliably exclude injury in penetrating trauma
70. • blunt or penetrating injury
• mortality: 10 - 20%
• may be associated with right lower rib fracture
• Signs / Symptoms
– RUQ pain abdominal wall spasm ,guarding
hypoactive or absent BS signs of hemorrhage
71. • Repeat CT rule out possible complications:
– Parenchymal infarction
– Hematoma
– Biloma
• Extrahepatic bile drained percutaneously.
• Intrahepatic collections of blood and bile
resolve spontaneously.
72. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
laceration
Subcapsular tear<10%surface area
Capsular tear <1cm parenchymal tear
II Hematoma
laceration
Sc tear,10-50%;intra parenchymal<10cm in diameter
Ct ,1-3 cm parenchymal depth,10cm in length
III Hematoma
laceration
Sc tear >50% surface area of ruptured sc/parenchymal
hematoma ,ip hematoma>10cm or expanding
>3cm parenchymal depth
IV Laceration Parenchymal disruption 25-75%hepatic lobe or 1 to3
segments
V Laceration
vascular
PD involving >75% of hepatic lobeor more thanone
couinaud segment within a single lobe
Juxtahepatic venous injuries
VI vascular Hepatic avulsion
74. • Blunt or Penetrating
• Signs / Symptoms
– LUQ pain
–Kehr’s sign
– involuntary guarding hypoactive or absent
BS
–signs of hemorrhage
– point tenderness
75. GRADE TYPE OF
INJURY
DESCRIPTION OF INJURY
I Hematoma
Laceration
Subcapsular tear <10%surface area
Capsular tear <1cm parenchymal depth
II Hematoma
Laceration
10-50%,intraparenchymal <5cm in depth
1-3cm,does not involve trabecular vessels
III Hematoma
laceration
>50% expanding/ruptured /ip hematoma> 5cm or
Expanding
>3cm with trabecular vessels involvement
IV Laceration Segmental/hilar vessels producing major
devascularisation
V Hematoma
Laceration
Completely shattered spleen
Hilar vascular injury devascularizes spleen
77. • Stomach & Small Bowel
– Blunt vs penetrating
• Diagnosis
– Pneumoperitoneum or free fluid on CT scan
– small bowel injury may be difficult to detect
– Found at laparotomy
79. • Colon
– Diagnosis
• Pneumoperitoneum or free fluid on CT scan
• injury may be difficult to detect
• Found at laparotomy
• Rectum
– Intraperitoneal- treat as colon injury
– Extraperitoneal- primary repair with
diversion
• +/- presacral drains
81. • Diagnosis
– often delayed diagnosis
– frequently seen together
– most often contused due to blunt injury
– Seen on CT Scan or at laparotomy
– intramural hematoma in wall of duodenum
obstruction bilious vomiting severe abdominal
pain distention
82. PELVIC INJURY
• Introduction
– significant blood loss if bilateral
–may settle in retroperitoneal space
–3% of all fractures
–mortality 8 - 50%
–2nd most common cause of traumatic
death
86. – The small bowel occupying the large portion is
more prone.
– Injury to the major vessels or liver- early shock.
– Patient presenting with shock in penetrating
injury- exploration.
– Hollow visceral injuries – sepsis.
87. – Increasing tenderness, total count elevation, fever
several hours after injury – surgery.
– Local wound exploration.
– Laproscopy.
– Gun shot wounds must be explored
88. Stab wounds
involve the chest in up to 10% of cases.
Most stab wounds do not cause an
intraperitoneal injury
The incidence varies with the direction of entry
into the peritoneal cavity
The liver, followed by the small bowel, is the
organ most often damaged by stab wounds.
89. Gun shot
• the degree of injury depends .
• amount of kinetic energy imparted by the
bullet to the victim
• mass of the bullet and the square of its
velocity
• Distance .
90. • type I wounds: long range (>7 yards) , a
penetration of subcutaneous tissue and deep
fascia only.
• Type II wounds: distance of 3 to 7 yards and may
create a large number of perforated structures.
• Type III wounds occur at point-blank range (<3
yards) and involve a massive destruction of tissue