Gunshot Trauma Research Articles

Detection of Gunshot Primer Residue on Bone in an Experimental Setting—An Unexpected Finding*

Pork ribs with intact muscle tissue were used in an experimental attempt to identify bullet wipe on bone at distances from 1 to 6 feet with 0.45 caliber, full metal jacket ammunition. This resulted in the unexpected finding of primer-derived gunshot residue (GSR) deep within the wound tract. Of significance is the fact that the GSR was deposited on the bone, under the periosteum, after the bullet passed through a Ziploc bag and c. 1 inch of muscle tissue. It is also important to note that the GSR persisted on the bone after the periosteum was forcibly removed. The presence of primer-derived GSR on bone provides the potential to differentiate gunshot trauma from blunt trauma when the bone presents an atypical gunshot wound. In this study, the presence of gunshot primer residue at a distance of 6 feet demonstrates the potential for establishing maximum gun-to-target distance for remote shootings.

Insurance Coverage Is Associated with Mortality after Gunshot Trauma

Poor access to adequate health care coverage is associated with poor outcomes for many chronic medical conditions. We hypothesized that insurance coverage is also associated with mortality after gunshot trauma. The trauma records for gunshot victims and their insurance status were reviewed at our center from January 1998 to December 2007. Patient demographics (age, gender, race, and insurance coverage), injury severity, hospital care (operations and radiographic studies), and in-hospital mortality were analyzed. There were 2,164 gunshot trauma activations reviewed during the study period. One-quarter (n = 544) of these patients had insurance and three-quarters (n = 1,620) were uninsured. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5). Insured patients did not differ from uninsured patients with respect to mean Injury Severity Score ([ISS] 12.2 +/- 10.7 vs 12.6 +/- 12.4, p = 0.56); similar percentages of patients were severely injured (ISS 16 to 24, 17% vs 15%, p = 0.19) and most severely injured (ISS > 24, 15% vs 16%, p = 0.68). Insured patients did not differ from uninsured patients with respect to use of radiographic imaging (53% vs 50%, p = 0.15) or operative intervention (37% vs 35%, p = 0.35). Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. This difference could not be attributed to demographics or hospital resource use. Insurance coverage may reflect the many social determinants of health. Improving the social determinants of health in patients affected by violent trauma may be a step toward improving outcomes after trauma.

Comparison of Isolated and Concomitant Liver Injuries: is Hepatic Trauma Entirely Responsible for the Outcome ?

Objective: This study was undertaken to examine both isolated and concomitant liver injuries to clarify the role of liver trauma on outcome.Patients and methods: This retrospective study was a review of all abdominal trauma patients who presented with liver injuries, with or without concomitant injury at Ege University School of Medicine over a 3-year period. Presentation, injury grade, management, and outcomes were analyzed. Patients with isolated hepatic injury (Group A) were compared with patients who had concomitant hepatic injury (liver and spleen/small bowel) (Group B). Significance was set at 95% confidence intervals.Results: Of 368 patients, 80 (21%) presented with liver injury. Of these, the aetiology was as follows: 53 (66.2%) blunt injury, 19 (23%) penetrating injury, and 8 (10%) gun shot trauma. There were 38 patients in Group A and 42 in Group B. Of these 42 patients, 19 were diagnosed with serious types of injury; eight thoracic, three open long bone fracture, one intra-cardiac, one intracranial. Six additional patients were observed with injuries to large abdominal vessels. Eleven patients (28.9%) with isolated hepatic injury were managed non-operatively. Mortality, intensive care unit and hospital length of stay, and transfusion requirements were significantly higher in Group B. Only the number of transfused blood units and the grade of liver injury were found to be effective on outcome whereas stepwise regression analysis revealed that injury type (penetrating) and blood transfusion were predictive for mortality.Conclusion: This study highlighted that although isolated liver injury results in good outcome with non-operative management, concomitant injuries to the liver lead to a higher failure and mortality rate. However, liver injury itself is rarely responsible for death.

Nurse Anesthetist Follow‐up of an Adolescent Female With Gunshot Trauma: A Case Study

PURPOSE. This case study was written to demonstrate the usefulness of standardized nursing diagnoses, outcomes, and interventions in nurse anesthetist care of an adolescent trauma patient. DATA SOURCES. Literature reviews using Academic Premier, Google Scholar, and CINAHL databases were done to find current, relevant articles concerning evaluation and support of female African-American adolescents living in socially vulnerable and economically exploited environments. DATA SYNTHESIS. A case is presented and evidence from current publications is analyzed to support the diagnosis, outcomes, and interventions. CONCLUSION. The investment in extra time, care, and effort sometimes required for the full development of a treatment plan for teenagers who live where they are at high risk for violence and other consequences of stressful environments is a worthwhile one, even if results may require contact over an extended time period. PRACTICE IMPLICATIONS. Nurses of all specialty backgrounds need to be concerned with the progress of their patients. Sometimes nurses can best serve their patients by stepping away from the physiological event and focusing instead on responses in the domain of coping and stress tolerance as the root of difficulties.

Successful Endoscopic Therapy of Traumatic Bile Leaks: Report of Fourteen Cases

Purpose: Traumatic bile leaks often result in prolonged morbidity and an increased length of hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our objective was to evaluate the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the management of a traumatic bile leak with resolution of the bile leak on follow-up ERCP. Methods: This is a retrospective case review of fourteen patients who were referred for ERCP after traumatic bile duct injury secondary to blunt (motor vehicle accident or motorcycle accident) or penetrating (gunshot) trauma for management of bile leaks. The data was collected over a 5-year period from a tertiary academic referral center. All patients underwent ERCP with biliary stent placement. Results: Fourteen patients underwent ERCP for the management of a traumatic bile leak over a 5-year period. The etiology included blunt trauma from motor vehicle accident in eight patients, motorcycle accident in three patients and penetrating injury from a gunshot wound in 3 patients. Liver injuries were grade III in 1 patient, grade IV in 10 patients, and grade V in 3 patients. All patients were treated by biliary stent placement, and the outcome was successful in 14 of 14 cases (100%). The mean duration of follow-up was 85.6 days (range, 54 to 175 days). There were no ERCP-related complications. Conclusion: Endoscopic management with endobiliary stent placement was successful and resulted in resolution of the bile leak in all fourteen patients. Based on the results of this study, consideration should be given to ERCP being a first-line therapy in management of traumatic bile leaks.Table

“At the sharp end”: does ambulance dispatch data from south Yorkshire support the picture of increased weapon-related violence in the UK?

Objective: To assess whether ambulance responses in South Yorkshire to stabbing, gunshot, penetrating trauma cases have increased over the past few years, supporting the observed increase in media reporting. Methods:...

Insurance coverage is an independent predictor of mortality after gunshot trauma

Insurance coverage is an independent predictor of mortality after gunshot trauma

Severe penile injuries: a problem of severity and reconstruction

To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation. We analysed retrospectively 43 patients (mean age 28 years, range 5-52 years) with severe penile injuries referred to us from March 1999 to August 2007. The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self-amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury. The mean (range) follow-up was 47 (10-108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two. Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres.

Despite the Increasing Use of Nonoperative Management of Firearm Trauma, Shotgun Injuries Still Require Aggressive Operative Management

The energy dissipation between gunshot and shotgun blasts is very different. Injuries from shotgun blasts vary depending on the distance of the victim from the shooter, the choke of the shotgun, the pellet load, and the wad of the ammunition. We postulated that gunshot and shotgun blasts create different injury patterns that dictate different treatment plans. Medical records of patients with gunshot and shotgun trauma were reviewed from 1998 through 2007 at our university-based trauma center. Statistical comparisons were made via Fisher's test or t-test calculations. We evaluated 2833 patients injured by firearms; of these 61 had shotgun wounds (2.2%). The remainder sustained gunshot wounds. Mortality between shotgun and gunshot trauma patients was similar (7% versus 9%, respectively, P=0.8). There was no difference in the mean Injury Severity Score (ISS) (13.7+/-1.6 versus 12.9+/-0.2; P=0.6). Overall, 61% of patients underwent operative intervention after shotgun injuries versus 36% of patients with gunshot wounds (P<0.0001). Patients surviving shotgun injuries had a longer length of stay (10.1+/-2.0 d versus 5.9+/-0.21, P<0.05). Although the injury severity was similar, injuries from shotguns required more operations and resource utilization. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous.

The anesthetic management of a venous bullet embolism to the right ventricle: A case report.

Bullet embolism is a rare complication of non-penetrating gunshot trauma. There are two types of bullet embolisms: arterial and venous. Accurate preoperative localization of the bullet is important for selecting the proper surgical and anesthetic techniques. We report here on a rare case of venous bullet embolus to the right ventricle from the right iliac vein, as was demonstrated by transesophageal echocardiography.

Modern Management of Complex Open Abdominal Wounds of War: A 5-Year Experience

Optimal management of the open abdomen remains controversial. Retrospective review of patients injured during Operations Enduring Freedom and Iraqi Freedom returning to Walter Reed Army Medical Center (WRAMC) from January 2003 to October 2007 for treatment of open abdomen. Three hundred fifty-four patients were evacuated to WRAMC after laparotomy, including 86 patients (24%) with open abdomen. Three transferred patients were excluded. Eighty-three patients, mean age 26 years (range 18 to 54 years), sustaining injury from secondary blast (n = 47), gunshot (n = 29), and blunt trauma (n = 7) were studied. Surgical management included early definitive abdominal closure (EDAC, n = 56; 67%), primary fascial closure (n = 15; 18%), planned ventral hernia (PVH, n = 9; 11%) and vacuum-assisted closure with AlloDerm (n = 3; 4%). EDAC closure involves serial closure with Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh (62%) or AlloDerm (31%). There was no substantial difference in injury mechanism, age, length of evacuation to WRAMC, or Injury Severity Score (average 30) according to closure type. Complications included removal of infected prosthetic mesh in 4 EDAC closure patients (5%). Overall morbidity was lowest (60%) in primary repair patients (p = 0.01). Rates of deep venous thrombosis, pulmonary embolism, abdominal wall hematoma, and infection did not differ between groups. Fistula rate was increased with PVH (20%). Two patients with PVH died. PVH and EDAC mesh complications have been minimized in the last 2 years of the study. Primary closure of fascia is ideal but not always possible. Early definitive closure has avoided PVH. Mesh-related complications have decreased with time.

Mandibular reconstruction after gunshot trauma in a dog by use of recombinant human bone morphogenetic protein-2

A 6-year-old German Shorthaired Pointer was evaluated for possible reconstruction of a mandibular defect resulting from gunshot trauma. A 5-cm defect of the right mandibular body was evident. A segment of the mandibular body was removed 9 weeks earlier because of severe contamination and comminution associated with gunshot trauma. Subsequent right-sided mandibular drift resulted in malocclusion in which the left mandibular canine tooth caused trauma to mucosa of the hard palate medial to the left maxillary canine tooth. The right maxillary canine tooth caused trauma to gingiva lingual to the right mandibular canine tooth. The right mandible was stabilized with a 2.0-mm maxillofacial miniplate positioned along the lateral alveolar margin and a 2.4-mm locking mandibular reconstruction plate placed along the ventrolateral mandible. An absorbable compression-resistant matrix containing collagen, hydroxyapatite, and tricalcium phosphate was soaked in recombinant human bone morphogenetic protein-2 (rhBMP-2; 7.2 mL of a 0.5 mg/mL solution for a dose of 3.6 mg) and placed in the defect. By 4 weeks after surgery, an exuberant callus was evident at the site of the defect. By 7 months after surgery, the callus had remodeled, resulting in normal appearance, normal occlusion, and excellent function of the jaw. Mandibular defects resulting from gunshot trauma can be treated by removal of contaminated tissue and comminuted bone fragments, followed by staged reconstruction. The combination of rhBMP-2 and compression-resistant matrix was effective in a staged mandibular reconstruction in a dog with a severe traumatic mandibular defect.

Suicide by Blasting Caps: A Case Study of Rare Cranial Trauma*

Suicide is a deliberate act of ending one's life. Suicide by use of any explosive device, when not involved in a terrorist act, is quite rare in occurrence when compared with other methods routinely utilized. In this paper, we present to the medicolegal community a case of an adult male who committed suicide with blasting caps and the subsequent extensive damage to the cranial hard tissue. Although the cause and manner of death were relatively straightforward, consultation with forensic anthropologists was requested for an anthropological trauma assessment of the highly fragmented skull. After the skull was cleaned and reconstructed, the analysis revealed similarities between blasting cap trauma to the head and high velocity gunshot trauma to the head. Therefore, in a case where some evidence may have been removed or destroyed, forensic analysis involving trauma of this magnitude could result in a misinterpretation of the true mechanism responsible for the osseous damage. In this case, cooperation among the law enforcement agency, coroner's investigators, the forensic pathologist, and forensic anthropologists provided a comprehensive death case analysis.

Lodox/Statscan provides rapid identification of bullets in multiple gunshot wounds

Lodox/Statscan is a new digital radiograph machine with low-dose radiation exposure. It provides rapid and whole-body scans. In multiple gunshot trauma, the conventional radiograph or computed tomography scan might be time consuming, and the resuscitation might be paused temporarily. We applied the Lodox/Statscan to search bullets within a short period, and the resuscitation was nonstop during imaging study. As a result, it serves as a valuable adjunct in providing rapid identification of metal projectiles in multiple gunshot wounds.

Reflexões sobre o trauma cardiovascular civil a partir de um estudo prospectivo de 1000 casos atendidos em um centro de trauma de nível I: a prospective study from 1000 cases

OBJETIVO: Analisar os dados referentes a uma grande série de casos de traumas cardiovasculares exclusivamente civil operados em um único centro de trauma brasileiro. MÉTODO: Trata-se de um estudo de coorte, prospectivo, descritivo e analítico registrados entre os anos de 1998 - 2005. RESULTADOS: No período foram operados 1000 casos que acometeram principalmente homens jovens devido a armas de fogo, armas brancas/vidros e trauma contuso e cuja topografia das lesões se deu na seguinte ordem: abdominais, cervicais, torácicas e extremidades. As três síndromes mais comuns a admissão foram: hemorrágica, isquêmica e hemorrágica/isquêmica. No entanto, 34.6% dos pacientes estavam em choque hipovolêmico grave e em 85% da casuística havia lesões não cardiovasculares associadas. A maioria dos pacientes foi submetida a tratamento cirúrgico sem propedêutica específica, mas 14% destes foram reoperados devido à síndrome compartimental, trombose aguda e/ou hemorragia grave. A taxa de amputação foi de 5.5% e da mortalidade de 7.5%, estando correlacionada com choque hipovolêmico grave ou síndrome da resposta inflamatória sistêmica. Lesões CCV isoladas ocorreram em 15% dos casos com taxa de letalidade global de 41%, sendo 22% venosa, 47% arterial e 81% cardíaca, proporcionando diferença significativa entre lesões cardíacas versus arteriais e venosas associadas (p = 0,01; odds ratio de 7.37) e lesões arteriais versus venosas (p = 0,01; odds ratio de 3.17). CONCLUSÃO: Esta grande série de casos demonstrou ser o homem jovem o mais acometido devido principalmente à violência interpessoal e os acidentes automobilísticos, que envolvem na maioria das vezes as extremidades, associadas com lesões em outros órgãos ou sistemas. Os fatores preditivos de mau prognóstico foram choque hipovolêmico, lesão de grandes vasos arteriais e lesão cardíaca.

Trauma-related infections in battlefield casualties from Iraq.

To describe risks for, and microbiology and antimicrobial resistance patterns of, war trauma associated infections from Operation Iraqi Freedom. : The invasion of Iraq resulted in casualties from high-velocity gunshot, shrapnel, and blunt trauma injuries as well as burns. Infectious complications of these unique war trauma injuries have not been described since the 1970s. Retrospective record review of all trauma casualties 5 to 65 years of age evacuated from the Iraqi theatre to U.S. Navy hospital ship, USNS Comfort, March to May 2003.War trauma-associated infection was defined by positive culture from a wound or sterile body fluid (ie, blood, cerebrospinal fluid) and at least two of the following infection-associated signs/symptoms: fever, dehiscence, foul smell, peri-wound erythema, hypotension, and leukocytosis. A comparison of mechanisms of injury, demographics, and clinical variables was done using multivariate analysis. Of 211 patients, 56 met criteria for infection. Infections were more common in blast injuries, soft tissue injuries, >3 wound sites, loss of limb, abdominal trauma, and higher Injury Severity Score (ISS). Wound infections accounted for 84% of cases, followed by bloodstream infections (38%). Infected were more likely to have had fever prior to arrival, and had higher probability of ICU admission and more surgical procedures. Acinetobacter species (36%) were the predominant organisms followed by Escherichia coli and Pseudomonas species (14% each). Similar to the Vietnam War experience, gram-negative rods, particularly Acinetobacter species, accounted for the majority of wound infections cared for on USNS Comfort during Operation Iraqi Freedom. Multidrug resistance was common, with the exception of the carbapenem class, limiting antibiotic therapy options.

An Anthropological Analysis of Gunshot Wounds to the Chest*

This analysis of gunshot trauma to the bony thorax examines 87 handgun and rifle wounds from documented cases in an effort to corroborate an earlier report and to provide the forensic community with additional literature in this area. Specifically, this study tests whether the trauma signatures associated with gunshot wounds in the bony thorax are useful in determining the direction of fire. Because the ribs occupy a significant portion of the bony thorax, they are struck more frequently than other bones and, consequently, they are the focus of this report. This study confirmed that bullets can leave distinctive markers on ribs that indicate the direction of fire, including depressed fractures, bone fragments displaced in the direction of the bullet's path, and beveling. Although forensic anthropologists can determine the direction that a bullet was traveling when it struck a given rib, they cannot give a definitive statement about the number or sequence of gunshots without supporting soft tissue evidence.

Forensic and criminologic aspects of murder in North-West (Epirus) Greece

Little information is presenting in Greek literature regarding forensic and criminological aspects of homicide in North-West Greece. Autopsy reports and the prosecution authorities’ files were respectively analyzed with regard to individual characteristics of perpetrators and victims, circumstances, and mode of commitment in order to comprehensively characterize relevant forensic and criminologic aspects. In the 8-year period from January 1998 to May 2005, 26 homicide cases were autopsied in the Department of Forensic Medicine and Toxicology, University of Ioannina, Greece. Twenty-nine homicide victims (18 males, 11 females; mean age 47 years) and 26 offenders were involved – 20 single, 4 multiple-offenders and 2 were not known (24 males, 2 females; mean age 35 years). The most common method used for homicide was gunshot trauma (41.4%). Head injuries and multiple trauma were the most common cause of fatal injuries. Most homicides took place outside in a deserted area or close to agricultural side ( n = 12). Fifty percent ( n = 13) of all cases the offender and the victim were known to each other (acquaintances). Twenty-three cases were categorized as “single” homicides and 3 as “multiple” and the victims were classified; 20 as murder–physical injury with fatal outcome, 2 homicide–suicide, 1 infanticide, 4 matricide, and 2 as patricide.

A case for Sherlock Holmes: forensic investigation of a gunshot wound to the head dating from Victorian London

AbstractThis is an investigation of a fatal gunshot wound that occurred over a century ago, in Victorian England. Records dating from 1900 show that it was regarded as suicide by officials of the time. Forensic, palaeopathological, and historical techniques are applied in order to determine whether the manner of death was suicide, murder, or accident. Comparison of the projectile trajectory with modern forensic series suggests that this case is statistically more likely to have been a murder than a suicide. This raises the possibility that a killer successfully staged events to appear as if a suicide had taken place. A summary is given of the important points to consider when interpreting gunshot trauma to the head in skeletal remains. Copyright © 2006 John Wiley &amp; Sons, Ltd.

Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit

An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.