Removal Of Bullet Research Articles

Civilian gunshot wounds of the spine: A literature review

The incidence of gun-related violence continues to rise, although accurate statistics are difficult to obtain. Up to 17% of spinal cord injuries are gunshot related. The recent literature pertains to the management of high velocity/energy gunshot wounds as encountered in war scenarios such as Iraq, Afghanistan, etc. The treatment of civilian gunshot wound injuries to the spine has not been clearly stipulated, and many treatment modalities are adopted from the treatment of war injuries, which is a completely different scenario. AIM: To evaluate the available literature pertaining to civilian gunshot wound injuries of the spine and the treatment thereof with regard to the indication for bullet removal, antibiotic prophylaxis, lead poisoning, the use of imaging modalities and fracture stability CONCLUSION: Although the literature is often conflicting and published case series are outdated, there is consensus that not all bullets or fragments need to be removed; the majority of fractures are stable; MRI is a safe imaging modality; lead poisoning is extremely rare; and extended antibiotics prophylaxis is not needed The indications for bullet removal is deteriorating neurology, intra-canal bullets between T12 and L4 with incomplete neurology, sepsis and lead poisoning should it occur.

Civilian Gunshot Wound to the Spine: 87 Cases

Introduction Penetrating spinal cord injury (SCI) by gunshot is relatively common in Brazil, and the literature available is scarce. This study aims to report the experience of a level I trauma center, exploring epidemiological data, clinical features, treatment, and outcomes of victims of gunshot wound to the spine. Material and Methods A retrospective study was performed and included all victims of gunshot wound to the spine at João XXIII Hospital from April 2011 to March 2014 (36-month period). The epidemiological profile, topography of the injury, neurological status, treatment, and in-hospital morbidity and mortality are reported. Statistical analysis was performed on Epi Info 7.0 with Fisher exact test. Correlation with the current literature was conducted. Results A total of 1,088 patients were admitted with blunt and penetrating spinal injury in the 36 months evaluated. A total of 87 cases were gunshot wounds (8% of the 1,088 cases). A majority of the patients were men (93.1%) and young (76.1% are under 30 years). Topographically, 48% affected the cervical spine, followed by 32% in the thoracic spine. The motor status had a dichotomous presentation, with complete neurological deficit (ASIA A, 58.6%) and no neurological deficit (ASIA E, 27.6%). Incomplete neurological deficits represented a small number of cases. The vertebral instability, defined as the presence of acute or delayed deformity, was unusual (three cases, 3.4%). Almost 50% ( n = 44) of the patients had isolated spinal trauma and the remaining presented with associated traumas. Thoracic trauma was the most prevalent, followed by abdominal and facial injury. Only 10 patients (11.5%) required surgical treatment: laminectomy with bullet removal in 7 cases and instrumented fixation in the remaining 3. Infection was present in five cases: four postoperative infections and one in a patient with nonoperative management. Surgical treatment was associated with a 50-fold increase risk of infection ( p = 0.0004). CSF fistula was observed in only one case after surgical treatment and because of the rarity of the event, a statistical analysis could not be performed. Overall mortality was 14.9% (13 patients) and was more common in patients with cervical lesions (10 patients). Associated trauma was present in 70% of the patients who died, but did not acquire statistical significance ( p = 0.1) with mortality risk. Conclusion Gunshot wound to the spine is common in our population, affecting especially young men, associated with neurological deficit in two-thirds of the patients. Instability is a rare event in these patients (3.4%) and surgical treatment was associated with a significant risk of infection.

Combat-related intradural gunshot wound to the thoracic spine: significant improvement and neurologic recovery following bullet removal.

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.

A bullet in the supraspinatus compartment successfully removed by arthroscopy: case report and review of the literature.

Arthroscopic removal of bullet from intra-articular compartment has been described for several joints. Only few reports dealing with this condition in the shoulder have been reported especially for the glenohumeral and the subacromial compartments. We report the story of a fifty-seven-year-old man presenting a bullet in the supraspinatus compartment of his left shoulder successfully removed by arthroscopy.

Management of Intraoral Gunshot Injury – A Case Report

ABSTRACT Oral and Maxillofacial gunshot injuries are usually lethal due to close proximity with the vital structures. The severity of injury varies according to the caliber of the weapon used and to the distance from which the patient is shot. A case of gunshot injury that was successfully managed by surgical exploration and removal of bullet from left maxillary antrum under local anesthesia is presented. The initial care of facial gunshot wounds strictly adheres to the basics of trauma resuscitation. Early and appropriate surgical management have proved to be influential on the final outcome and aesthetic result. Treatment of gunshot injuries should be planned and carried out carefully. It takes different stages and procedures to achieve the targeted treatment plan. Prevention and control of infection are important in the success of the treatment.

Retained Bullet Removal in Civilian Pelvis and Extremity Gunshot Injuries: A Systematic Review

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances. We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments? A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included. No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal. The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

Impacts of two best management practices on Pb weathering and leachability in shooting range soils

This study investigated the impacts of two best management practices (BMPs) recommended by US Environmental Protection Agency on Pb weathering and leachability in shooting range soils. The two BMPs included replacing soil berm with sand berm and periodically removing bullets or shot from a berm. A column experiment corresponding to the first BMP was conducted by mixing the bullets with sand/soil, or placing bullets on the surface of sand/soil. After a 16-18-week incubation under high or low rainfall simulations, total Pb concentrations in sand were lower than that in soil. Total leachable Pb in sand (8.48 and 5.52μg kg(-1)) was also lower than that in soil (60.0 and 30.4μg kg(-1)) when bullets were mixed with sand/soil; however, they were comparable when bullets were placed on the sand/soil surface. These results indicate that lower Pb concentration in the sand than in soil may be attributed to reduced weathering of bullets. Mechanical removal of Pb bullets in the field transferred Pb from large to finer particles, increasing total Pb in the soil (<2mm) from 2,170 to 5,000mg kg(-1). In contrast, mechanical removal of Pb shot effectively reduced the shot in the soil by 86-92%. Thus, we concluded that, while replacing soil berm with sand berm can slow down Pb weathering, it may increase Pb leachability in the long term. Removal of Pb bullets and Pb shot can be effective, but caution needs to be exercised to minimize the adverse impacts, especially in pistol/rifle ranges because of increased total Pb content in the soil.

The Long-term Outcome of Retained Foreign Bodies in Pediatric Gunshot Wounds

The purpose of this retrospective review was to determine the long-term consequences of retained bullet foreign bodies in children after gunshot injury. All children managed for gunshot wounds at an urban, level I pediatric trauma center were evaluated, identifying those discharged with retained bullet foreign bodies. Overall, 244 children were treated for gunshot wounds, 107 (44%) had retained foreign bodies, 24 (22%) experienced long-term complications related to retained foreign bodies, and 14 (13%) required removal. Complications occur in a significant subset of pediatric patients with retained bullets. Prophylactic bullet removal appears unnecessary, although close outpatient follow-up is warranted.

Treatment strategy in a child with a retained bullet in the cerebellomedullary cistern

A 6-year-old girl was admitted to our emergency room because of a gunshot wound in the posterior craniocervical junction. On admission, she was alert, but left hemiplegia and right hemiparesis were noted. Cranial CT scanning showed a retained bullet in the cerebellomedullary cistern without bone destruction. Moreover, fourth ventricle hemorrhage was observed. There were no signs of acute hydrocephalus. The patient underwent suboccipital craniectomy and C-1 laminectomy for bullet removal. Postoperatively, the patient experienced significant neurological improvement. To the best of the authors' knowledge, this is the first documented case of a patient with a retained bullet in the cerebellomedullary cistern. The management strategies in such a unique case are discussed.

Removal of a bullet in the pericardial cavity by video-assisted thoracoscopic surgery

The use of video-assisted thoracoscopic surgery (VATS) in dealing with thoracic trauma has been well established. VATS avoids a thoracotomy and offers excellent visualization of the entire pleural cavity. The removal of bullets from the pleural cavity using VATS has also been reported, but, to our knowledge, this is the first time a bullet has been removed from the pericardial cavity using VATS.

Introduction to the fourth "Focus-on" issue devoted to Disaster and Military Surgery in EJTES.

Welcome to a new ‘‘Focus-on’’ issue devoted to the field of Disaster and Military Surgery! The fact that the Section for Disaster and Military Surgery is now responsible for its fourth issue of this kind since 2008 illustrates the continuously growing interest for this topic in Europe. The Section for Disaster and Military Surgery is also continuously growing and is recognized as one of the most active sections in the society, with an extensive educational program and several scientific projects. The extent of this field is also illustrated in this issue, which includes papers on disasters caused by both nature and climate as well as terror attacks, papers on wound ballistics, and a paper on the use of a simulation model for the evaluation of hospitals’ response to major incidents. One paper presents analyses of injury patterns from the Sichuan earthquake in China, thereby, continuing the valuable reporting from the earthquakes in China from the last ‘‘Focus-on’’ issue. We highly appreciate our colleagues from China selecting our journal for sharing their experiences with us and I think that we all are in agreement that their reports are valuable contributions to the knowledge in this field. We look forward to your continued contribution to the journal! Three papers deal with wound ballistics: two very valuable reviews, one on the indications for bullet removal, presenting proposals for practical clinical guidelines for European trauma surgeons, and another on the technical data of modern body armor, which is important knowledge in the evaluation and management of ballistic injuries. A third paper on wound ballistics is based on an analysis of the causes of death in patients with limb warfare trauma. A paper from Israel presents experiences from the use of a simulation model with a live exercise based on data from real patients for the assessment of hospital disaster plans. Since it is very difficult to perform prospective clinical studies in the medical response to major incidents, the need for relevant simulation models has been increasingly recognized during the last several years as a way to scientifically analyze and develop the methodology in planning and response. However, very few such models have been available so far, and this is an important field for further development. There is a need for the promotion of the scientific part of Disaster Medicine, and we hope that this forum in EJTES can contribute to that and also to a continuously increasing interest among trauma surgeons in this important field.

Spontaneous migration of a retained bullet within the brain: a case report

Gunshot injury to the head is usually mortal, and spontaneous migration of a retained bullet is rare. We report the case of a 23-year-old man with a spontaneously migrated bullet within the brain. Cranial computerized tomography (CT) indicated that the bullet was lodged deeply in the left parietal region. The patient was conscious and had right homonymous hemianopsia. The bullet was close to the vital structures and deep-seated; therefore, surgical intervention was not considered. Two months after the injury, repeat CT revealed that the bullet had migrated posteriorly and caudally due to gravitational factors. Management of the retained bullet was controversial. Removal of a deep-seated bullet may cause additional neurological deficit, but migration of a retained bullet may cause damage to vital structures, producing significant neurological damage. We proposed that the bullet in the brain should be removed if it could be reasonably accessed without causing additional neurological damage.

Intracerebral bullet removal through an endoscopic transnasal craniectomy

Background:In the past decade, the endoscopic transnasal technique has been broadly applied as a feasible and less invasive approach to the skull base. The adaptability of the endoscopic technique allows a case-specific approach in order to minimize both endonasal and cranio-cerebral manipulation; therefore it can be also used in patients complaining exceptional skull base lesions and in weak patients. The objective of this paper is to present the first case of intracerebral bullet removal using a pure endoscopic transnasal route through a custom made unilateral craniectomy.Case Description:A 59-year-old patient was admitted to the emergency department after a gunshot injury to the head, thorax, abdomen, and pelvis. Admission Glasgow Coma Scale was 7. Brain computed tomography (CT) scan highlighted a right occipital hole defect due to perforative impact, intracerebral dislocations of bone fragments, right intracerebral and subdural hematoma, and midline shift to the left side; the bullet was localized in the right frontal lobe and its tip was in contact with the ethmoid roof.The patient underwent emergency decompressive craniectomy and evacuation of the subdural hematoma and abdominal explorative laparotomy, ileum resection, and gastrorrhaphy. After 1 month, the patient underwent endoscopic transnasal removal of the bullet and skull base reconstruction due to cerebrospinal fluid infection. The postoperative course was uneventful and he has done well in follow-up with no evidence of cerebrospinal fluid leak and preservation of olfaction.Conclusion:The adaptability of the endoscopic transnasal technique offers patients complaining exceptional skull base lesions a case-specific strategy minimizing morbidity and postoperative stay.

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons.

The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices. We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature. 145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds. In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.

Management of Gunshot Pelvic Fractures With Bowel Injury: Is Fracture Debridement Necessary?

Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomyelitis in these injuries. A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debridement was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection.

Intra-myocardial Bullet causing heart block in a patient with multiple gunshot wounds: Case Report

Elective removal of intra-myocardial bullet remains a controversial subject. A non-operative approach has been recommended as appropriate for a stable asymptomatic patient. In the presence of complications such as bleeding, perforation leading to cardiac tamponade, thrombus formation, embolization, rhythm disturbances and infections, surgical removal may be advised. We present a patient who survived multiple gunshot wounds with a bullet lodged in the wall of the left ventricle of the heart. Details of the injuries sustained, operative removal of the bullet and the challenges that ensued are illustrated.

Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons. A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post-Vietnam War period was undertaken. Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit. Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24-48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.

Arthroscopic bullet extraction from the hip in the lateral decubitus position

Hip arthroscopy was first described in 1931 by Burman, and in recent years the applications have extended to labral surgery, osteochondroplasty, and a variety of other procedures. Hip arthroscopy may also be employed to extract loose or foreign bodies from the hip, and may be associated with more rapid recovery than an open procedure. We present a case of arthroscopic bullet removal from the hip in a 24-year-old man.

SH05 THE CONTRIBUTION OF THEODORE BILLROTH TO THE MANAGEMENT OF WAR WOUNDS IN THE FRANCO‐PRUSSIAN WAR 1870–1

The outcome of war wounds until the late 1800s was dismal, with most significant wounds showing “putrefication and suppuration” prompting surgeons to employ a high rate of amputation. At this time a “spontaneous generation theory” was popular – wound infection being attributed to toxins released by dying tissues. Pasteur's Germ Theory was yet to be published.Billroth spent a summer vacation as a military surgeon during the Franco‐Prussian war (1870–1), a campaign that marked the birth of Germany as a nation. By then Billroth, aged 41, was Professor of Surgery in Vienna, and had already published a book on gunshot wounds in which he had advocated primary closure.He was posted behind the frontline in military hospitals, first in Weissenburg and then in Mannheim. His wartime observations included missile projectiles, prevention of suppuration, removal of bullets, and the impact of a fracture on the risk of infection. On arrival in Mannheim, the incidence of erysipelas had been alarming, but he reduced infection rates by simple hygienic measures, adopting, but modifying, some of Lister's principles of anti‐sepsis. For amputation, he stressed haemostasis, approximation of layers, but allowing open drainage and healing by secondary intention. In October 1870 he had almost 100 patients transferred from Weissenburg to Mannheim so he could study their progress. There was only once case of gangrene.Conclusion: Billroth's involvement in the Franco‐Prussian war resulted in progress in the treatment of war wounds. He changed his original management, established without much experience in Zurich, to advocate cleansing, dilute antiseptics, and open drainage.

Embolia balística venosa retrógrada transtorácica: relato de caso e revisão da literatura

Êmbolo balístico é um fenômeno de ocorrência rara no atendimento ao traumatizado. Geralmente, são pouco sintomáticos ou assintomáticos, e o tratamento desses pacientes, apesar de estar em constante evolução, é ainda controverso. A abordagem endovascular tem se destacado como modalidade de tratamento para esse tipo de embolia com baixa morbimortalidade. Este artigo relata o caso de um paciente de 30 anos, do sexo masculino, vítima de ferimento por arma de fogo com múltiplos orifícios de entrada em tórax, submetido com sucesso à retirada do projétil por acesso endovascular após tentativa frustrada de retirada por toracotomia.