Penetrating Trauma Research Articles

A case of Japanese spotted fever with purpura fulminans.

Early intervention is imperative in cases of JSF due to its potentially fatal trajectory if diagnosed belatedly. JSF should be contemplated in the differential diagnosis when generalized purpura, accompanied by a pronounced inflammatory response, is noted, even in the absence of a puncture wound.

Penetrating intraorbital wooden foreign bodies involving the right frontal lobe of the brain: A rare case report

Background: Penetrating orbital trauma from a wooden foreign object is rare and challenging to identify, as it cannot be detected with a computed tomography (CT) scan. This report highlights the clinical presentation, diagnosis, and management of such a case. Case Description: A 19-year-old female experienced penetrating orbital trauma from a wooden object following a traffic accident. She intermittently visited the hospital with eye swelling and headache, without visible penetrating wounds on the palpebra. The swelling persisted for weeks, accompanied by increasing signs of ocular and cerebral infection. The suspicion of a non-metallic foreign body penetrating the brain was confirmed 3 months after the initial visit, delayed by the hidden entry wound between the eyelid and eyeball and orbital edema mimicking non-penetrating trauma. A multidisciplinary team managed the case. Procedures included debridement, retro-orbital exploration, retro-orbital abscess evacuation, and frontal basal trephination exploration, successfully removing the wooden object that had penetrated the medial orbit, frontal bone, and brain, along with cerebral abscess evacuation. Postoperative CT scans showed complete removal of the foreign object and successful abscess evacuation. The patient showed improvement in ocular symptoms, resolution of headaches, and no wound leakage. She was discharged on the 14th day after completing antibiotic treatment and having the dressing removed. Conclusion: This case is notable for its rarity, high risk of misdiagnosis, and potentially fatal consequences if not promptly managed. We emphasize the importance of patient involvement in routine consultations, careful anamnesis, clinical examination, and a multidisciplinary approach for optimal outcomes.

Transorbitary intracranial penetrating injury involving bicycle brake handle: case report and literature review

Transorbitary intracranial penetrating injury involving bicycle brake handle: case report and literature review

Evaluation of New Mental Health Diagnoses After Pediatric Traumatic Injuries at a Level 1 Pediatric Trauma Center.

Traumatic injury is associated with significant mental health morbidity. To evaluate the need for implementation of active-post injury mental health screening at a Level 1 Pediatric Trauma center, we aimed to characterize all new mental health diagnoses after injury and evaluated for patient or injury factors that may aid in targeting of future screening. A single-center retrospective analysis of trauma patients aged 6-18years presenting in 2022 was performed. Our primary outcome was a new DSM-5 mental health diagnosis documented after traumatic injury. Patients with and without a new mental health diagnosis were compared by age, sex, race, ethnicity, injury type/mechanism, injury severity score (ISS), intensive care unit (ICU) admission, and length of stay (LOS). 492 patients were included. Their median (IQR) age was 13.5 (10.4, 15.4) years. The median (IQR) follow-up interval was 157 (9, 429) days. There were 24 (4.9%) children with a new mental health diagnosis: 12 (50%) with trauma-related stress disorders, with the remaining having diagnoses such as depressive or anxiety disorders. Patients with a new mental health diagnosis had longer LOS (3.0 [1.8, 7.5] vs 2.0 [1.0, 3.3] days, P = 0.02) and were more likely to have sustained penetrating injury (P = 0.01). There were no differences in demographics, rates of preexisting mental health diagnosis or area deprivation index (P > 0.05). There were fewer new mental health diagnoses in our cohort than expected, likely underestimating the acute need. Comprehensive post-injury screening is imperative to sufficiently identify and intervene upon mental health morbidity after pediatric trauma.

Traumatic Diaphragmatic Rupture Leading to Tension Gastrothorax: A Critical Case Report and Surgical Insight

Traumatic diaphragmatic rupture (TDR) is a serious but relatively uncommon injury, often resulting from blunt trauma, particularly motor vehicle accidents. Among these, blunt TDR presents with more severe outcomes than penetrating injuries, including higher mortality rates. A life-threatening complication of TDR is gastrothorax, which occurs when the stomach herniates into the thoracic cavity, leading to elevated intrathoracic pressure and potentially fatal consequences such as respiratory failure or cardiac arrest. This case reported a 23-year-old male who sustained a motor vehicle collision, presenting with progressive shortness of breath, nausea, and vomiting 15 hours post-injury. Imaging confirmed a diaphragmatic rupture with associated tension gastrothorax. Immediate intervention with nasogastric tube placement provided symptom relief, followed by exploratory laparotomy to repair the diaphragmatic defect. The patient's recovery was uneventful, demonstrating the critical importance of early diagnosis and timely surgical management in cases of TDR with gastrothorax. Traumatic diaphragmatic rupture occurs in approximately 0.8–1.6% of trauma cases, with motor vehicle accidents being the leading cause. Due to its potential for delayed diagnosis, the rupture is often missed initially, leading to higher rates of morbidity and mortality. Early detection is critical, as it can prevent serious complications such as bowel herniation into the thoracic cavity, respiratory distress, or even death.

Thoracic irrigation for traumatic hemothorax: A systematic review and meta-analysis.

Traumatic hemothoraces (HTXs) are common, and tube thoracostomy (TT) insertion is generally the initial management. However, a retained HTX can develop into a fibrothorax or empyema requiring secondary intervention. We hypothesized that irrigation of the thoracic cavity at the time of TT may prevent retained HTX. Pubmed, EMBASE, and Scopus were searched from inception to May 2024. Studies with adult trauma patients with traumatic HTX who received a TT and had patients who underwent thoracic irrigation were included. The primary outcome was failure rate, defined as retained HTX requiring a second intervention. Cumulative analysis was performed with χ2 for dichotomous variables and unpaired t test for continuous variables. A fixed-effects model was applied for meta-analysis. Six studies were included in the analysis; two retrospective and four prospective observational studies. These studies included 1,319 patients (513 irrigated TT, 837 nonirrigated TT). The mean age of patients was 45 years, 81% were male, mean Injury Severity Score was 21, and 42% had penetrating trauma. Failure rate was significantly lower in the irrigation group on cumulative analysis (10.7% vs. 18.2%, p < 0.001) and meta-analysis (effect size, 0.704; 95% confidence interval, 0.218-1.190; I2 = 0.4; p < 0.001]. In addition, on meta-analysis, the irrigation group had a shorter TT duration and hospital and ICU length of stay (all p < 0.05). There were no differences in overall infectious complications, readmission, or mortality; however, all the models favored the irrigation group. Patients who undergo simultaneous TT and thoracic irrigation have a lower rate of retained HTX and require fewer secondary interventions. Thoracic irrigation for traumatic HTX should be considered; however, randomized studies are needed prior to development of guidelines. Systematic Review/Meta-analysis; Level III.

Deep learning-based human gunshot wounds classification.

In this paper, we present a forensic perspective on classifying gunshot wound patterns using Deep Learning (DL). Although DL has revolutionized various medical specialties, such as automating tasks like medical image classification, its applications in forensic contexts have been limited despite the inherently visual nature of the field. This study investigates the application of DL techniques (59 architectures) to classify gunshot wounds in a forensic context, focusing on distinguishing between entry and exit wounds and determining the Medical-Legal Shooting Distance (MLSD), which classifies wounds as contact, close range, or distant, based on digital images from real crime scene cases. A comprehensive database was constructed with 2,551 images, including 1,883 entries and 668 exit wounds. The ResNet152 architecture demonstrated superior performance in both entry and exit wound classification and MLSD categorization. For the first task, achieved accuracy of 86.90% and an AUC of 82.09%. For MLSD, the ResNet152 showed an accuracy of 92.48% and AUC up to 94.36%, though sample imbalance affected the metrics. Our findings underscore the challenges of standardizing wound images due to varying capture conditions but reflect the practical realities of forensic work. This research highlights the significant potential of DL in enhancing forensic pathology practices, advocating for Artificial Intelligence (AI) as a supportive tool to complement human expertise in forensic investigations.

Effects of carbonization on gunshot residue detection in an animal model

The detection of gunshot residue (GSR) can be useful to determine if the wound has been caused by a firearm and it could help to differentiate the entry wound from the exit one. Carbonization is a good method for altering crime scenes. However, there are few studies in this specific context. The first objective of our study was to examine the persistence of GSR in wounds after carbonization. The second aim was to differentiate entry wounds from exit ones.For the experiment, bullets were fired with a 22LR on sheep limbs at contact range.The specimens were divided into four groups: two that weren't shot at (fresh and carbonized limbs) and two of shot limbs (one with carbonization and one without). Carbonization was performed in the open air using an accelerant.Wounds were analyzed using Scanning Electron Microscopy with Energy Dispersive X-ray spectrometry (SEM–EDX) and Inductively Coupled Plasma Mass Spectrometry (ICP-MS).Lead, Antimony and Barium were observed using SEM-EDX only in the entry wounds, while lead was found in the exit ones. ICP-MS enabled the detection of these elements in the entry and exit wounds but predominantly in the entry ones. After carbonization we observed a huge decrease of GSR. With SEM-EDX most of the particles detected were only consistent with GSR. Anyway, the identification of GSR and the differentiation between entry and exit wounds were still possible with both techniques. Therefore, they are suitable for detecting GSR in carbonized gunshot wounds under the specific conditions of our experiment.

Gunshot Defense Wounds: Three Case Reports and a Literature Review

Defense wounds generally occur when a victim attempts to protect vital organs and blood vessels during an assault, and are therefore typically located on the forearms or hands. Gunshot-induced defense wounds are less frequent compared to stab wounds, which have been extensively described in the literature. We present three cases where victims unsuccessfully attempted to defend themselves from gunshots, and where the detailed description of injuries played a key role in the reconstruction of the crime scenes. In the first case, a man was shot with a smooth-bore shotgun, presenting a “through-and-through” gunshot wound on the lateral surface of the left forearm and a large gaping wound on the posterior surface of the same forearm. The second and third cases involved two men who were shot with handguns. The first displayed an entrance wound on the dorsal surface of the right hand, with burned edges and smoke soiling, and an exit wound on the palmar surface. The second case involved two wounds on the left hand: one on the dorsum and the other on the palm. To the best of our knowledge, few studies in the literature emphasize the role of gunshot defense wounds in aiding the reconstruction of crime dynamics. The cases presented in this study highlight the importance of precisely defining the pathological and morphological features of the wounds, as well as the bullet trajectories, to accurately identify defense wounds. These findings are valuable for reconstructing the dynamics of the assault and providing critical information to the public prosecutor.

Evaluation of factors effecting survival of patients following massive transfusion and analyzing characteristics of massive transfusion protocol

Objective: To examine the impact of the time elapsed between a traumatic event and the implementation of a massive transfusion protocol on the patient outcomes and to analyze the characteristics of the protocol depending on the type of injury sustained. Methods: A total of 50 polytrauma patients who received blood transfusion by massive transfusion were included in the study. Demographic details, mechanism of injury, duration of time between injury, and other vital data were collected for analysis. Results: Our study revealed that the mean duration between the occurrence of injury and massive transfusion protocol activation (185 min) was highest among individuals who succumbed to their injuries within 1 hour and shortest among individuals who survived beyond the 24 hours following trauma (20.3 min) (P &lt; 0.005). Blunt trauma had a lesser mortality rate (35.1%) than the penetrating type of trauma (61.5%). The average amount of fresh frozen plasma administered to patients with penetrating trauma (3.15) was significantly higher than that of blunt trauma (2.35) (P &lt; 0.05). Conclusion: Delaying massive transfusion increases trauma patient mortality. Swift initiation of massive transfusion stabilizes severe blood loss cases. Varied blood product ratios and initiation times highlight the necessity for a standardized protocol.

Identification of gunshot entry wounds using hyperdense rim sign on post-mortem computed tomography.

Post-mortem computed tomography (PMCT) is an increasingly utilized tool in forensic medicine for evaluating head gunshot injuries. Vault bevelling sign, when present, provides information regarding entry and exit wounds; when absent, identifying wound type on PMCT remains challenging. A cutaneous hyperdense ring, described in an animal study by Junno et al. (2022), may be indicative of contact shots. We hypothesized that it could also be observed in human gunshot injuries. Our study evaluates the reliability of the cutaneous hyperdense rim sign for identifying entry gunshot wounds in PMCT. After excluding complex and mucosal wounds, two operators retrospectively evaluated 64 gunshot wounds (30 entry and 34 exit wounds) in 34 head PMCT cases (2018-2022). Gold standard for wound type determination was the autopsy report. The hyperdense rim sign was defined as at least two-thirds of a continuous cutaneous hyperdense circle on a multiplanar reconstruction of cutaneous tissue tangent to the wound. The hyperdense rim sign demonstrated a specificity of 97% (95% CI: 85-100%) and a sensitivity of 63% (95% CI: 44-80%) for identifying entry wounds. Moreover, in 16 external examination reports where the presence of powder residues or bullet wipe at entry wound was explicitly mentioned, a positive association was observed between hyperdense rim sign and the presence of these elements (p = 0.018). These findings suggest that the hyperdense rim sign, when present, may be a valuable tool for entry wound determination in gunshot injuries, interpreted in conjunction with other CT and autopsy features.

030. Delayed Presentation of Blunt Traumatic Diaphragmatic Hernia 15 Years After Injury: A Case Report

Background: Traumatic diaphragmatic rupture is rare with incidence between 0.8-8% and often resulting from blunt or penetrating trauma. We present a case of delayed diaphragmatic hernia in a 41-year-old male, 15 years after blunt abdominal trauma. Case: A 41-year-old male presented with dyspnea and severe abdominal pain. He reported being struck in the abdomen with wood during a gang attack 15 years prior. A year after the accident, he complained of uncomfortable breathing that worsened in the past 6 years. Physical examination revealed decreased breath sounds on the left side and a distended abdomen. Imaging confirmed bowel herniation into the left hemithorax, partial lung collapse, and a mediastinal shift. Emergency laparotomy revealed a 5 cm diaphragmatic defect, massive gastric necrosis, and herniation of abdominal organs into the thoracic cavity. The defect was closed with primary repair, and necrotic gastric tissue was excised and repaired using primary closure with omental patch. The patient recovered well and was discharged on day 11. Conclusion: Diaphragmatic ruptures require prompt surgical repair to prevent complications. Physicians must carefully evaluate trauma history and conduct thorough examinations to improve outcomes in emergency settings.

029. Management of Injury to The Right Lung Due to Penetrating Trauma to The Chest: A Case Report

Background: Thoracic trauma is a significant cause of mortality, in fact, many patients with thoracic trauma die after reaching the hospital. However, many of these deaths can prevented with prompt diagnosis and treatment. Less than 10% of blunt chest injuries and only 15 to 30% of penetrating chest injuries require operative intervention. Most patients who sustain thoracic trauma can be treated by technical procedures within the capabilities of trained clinicians. Case: We reported a case of 44-year-old female having a penetrating wound in her left chest because of her ex-husband stabbed her with a knife. The patient felt pain and the vital signs were stable, from the physical examination there were no abnormalities found. The surgeons did anterior thoracotomy and evacuated the knife within 2 hours since the patient arrived in the ER, and turned out the knife injured the right lung and there was bronchopleural fistula appeared. The surgeons did repair of the fistula and debridement of the wound and primary suturing carried out. The patient discharged 3 days after hospitalized with good clinical condition. Conclusion: This case report presents a successful management of a stable patient with penetrating chest trauma.

&lt;i&gt;Ochrobactrum anthropi&lt;/i&gt;: a rare case of endocarditis

Ochrobactrum anthropi is an aerobic Gram-negative bacillus, formerly known as “Achromobacter group Vd”. It is increasingly recognized as a potentially problematic, opportunistic, and nosocomial pathogen. Most cases of human diseases due to O. anthropi are associated with central venous catheter line infection; few case reports about infective endocarditis, pancreatic abscess, puncture wound osteochondritis, endophthalmitis, urinary tract infection, meningitis, pelvic abscess, and osteomyelitis are present in the literature. Among the previously stated infections it can cause, infective endocarditis is very rare; only four cases have been described in the literature. Here, we report the case of an immunocompromised man who developed native valve endocarditis with septic cerebral embolization due to O. anthropi.

Evaluation of an anthropometric head surrogate exposed to chisel-nosed fragment simulating projectile impact

Fragment-induced penetrating injuries pose a significant threat in modern combat. Explosions from explosive devices generate metallic fragments that can lethally penetrate various body regions, with the head being particularly most vulnerable to fatality in terms of penetration. Hence, understanding the head’s response to fragment impact is crucial. To this end, this study investigated the ballistic response of an anatomically accurate anthropometric head surrogate to fragment impact. The head surrogate comprised simulants for the three major layers of the head (skin, skull, and brain). Using a pneumatic gas gun, we impacted chisel-nosed fragment simulating projectiles (FSPs) of 1.10-g and 2.79-g on the head surrogate. We analyzed the ballistic response of the head surrogate in terms of ballistic limit velocities (V50), energy densities (E50/A), and failure mechanisms in each layer. The results indicated sensitivity to the FSP size. The 1.10-g FSP had a ∼41% higher V50 and a ∼63% higher E50/A compared to the 2.79-g FSP. Additionally, each head surrogate layer exhibited distinct failure mechanisms. The skin simulant failed due to a combination of shearing and elastic hole enlargement, forming a cavity smaller than the size of the FSP. The skull simulant fractured, creating a cavity at the entry point matching the FSP size. The brain simulant failure involved shearing of the cavity and penetration of fractured skull fragments. We also observed no significant difference in response when introducing a flexible neck attachment on which the head surrogate was mounted. Furthermore, comparisons of an anthropometric (close-shape) head surrogate with a simplified open-shaped head surrogate revealed the minimal influence of the head curvature on the response due to the localized nature of fragment penetration. These findings provide a comprehensive understanding of the head surrogate’s mechanical response to fragment impact. The insights from this work hold significant value in the assessment of penetrating head injury, especially against small fragments. The results can be applied in modern warhead design and forensic investigations.

Early Surgery and High Dose Steroids in Treating Patients with Indirect Traumatic Optic Neuropathy: A Meta-Analysis and Systematic Review

Introduction: Optic nerve injury is a devastating cause of permanent visual loss after blunt or penetrating injury occurring in up to 7% of head trauma cases. No single treatment strategy and timing of intervention has proved optimal. Timely and appropriate management is key to improving visual outcomes. We compared whether immediate surgical decompression or steroids would lead to improvement of visual outcomes in individuals with indirect traumatic optic neuropathy. Methods: We searched from several online databases and included studies of patients with direct Optic nerve injury, those who received combined treatment with surgery and steroids, and those with delayed initiation of treatment were excluded. Results: The final search yielded eleven eligible studies. Both interventions showed similar results in improvement of visual function (RR 2.35, 95% CI 0.87 to 6.34, p=0.09, I2 0%). Both early and late intervention also showed similar results in improvement of visual function (RR 1.72, 95% CI 0.89 to 3.35, p=0.11, I2 61%). Among patients who underwent early surgical decompression, the rate of visual acuity improvement was 73% with those who underwent transcranial surgery and 69% with those who underwent endoscopic surgery. Conclusion: This study shows that immediate surgical decompression and early high dose steroid administration are equally effective in improving visual function. Patients with no light perception (NLP) and light perception (LP) pre treatment resulted to better visual improvement with steroids while those with counting fingers (CF) and more than CF pre treatment, resulted to better visual improvement with surgical decompression.

027. Successful Management of Penetrating Thoracic Injury With Impaled Object: A Case Report

Background: Penetrating thoracic injuries with impaled objects are rare but potentially life-threatening emergencies that require immediate medical intervention. These injuries pose significant challenges due to the risk of pneumothorax, hemothorax, and lung laceration. Prompt diagnosis and surgical management are essential to prevent severe complications. Case: A 28-year-old male was admitted to Adam Malik Hospital with a chief complaint of shortness of breath following an accident where a foreign object impaled his right chest. The injury occurred while he was repairing his motorcycle, and an explosion caused the object to penetrate his chest. The patient reported continuous right chest pain, worsened by breathing. On examination, he was alert with stable hemodynamics (BP: 130/70 mmHg, HR: 98 bpm, SpO2: 99% on 10L NRM), and a penetrating wound of 5x2x3 cm was observed in the right chest. Chest X-ray and clinical assessment confirmed a diagnosis of hemopneumothorax with an impaled object. Emergency thoracotomy revealed 800cc of hemorrhagic fluid, lung laceration, and a foreign body penetrating the right lung's superior and medial segments. The foreign body was removed, the lung was sutured, and a thoracic drain was placed. Conclusion: This case highlights the importance of timely surgical intervention in penetrating thoracic injuries. Hemodynamic stability and appropriate surgical techniques led to a successful outcome in this patient, demonstrating the effectiveness of rapid, multidisciplinary management in emergency thoracotomy.

Rescuing the knee: arthroscopic extraction of a long-neglected glass fragment: a case report

The knee joint frequently encounters penetrating injuries and has ample space to harbor foreign objects. While foreign bodies in the knee joint are unusual, especially those not originating from surgical procedures, extensive literature exists on the extraction of loose bodies and metallic objects from this articulation. However, documentation on uncommon intruders remains scarce. This case study delves into the experience of a 22-year-old male who suffered persistent pain due to a neglected foreign object in his knee joint. After its removal, a complete resolution of symptoms was achieved. It highlights the importance of prompt arthroscopic intervention for optimal outcomes. Here we present a unique case involving a 22-year-old male who underwent arthroscopic retrieval of a neglected glass fragment from his knee joint. The patient sought medical attention five months after the initial injury due to sudden and severe pain onset. Arthroscopy stands as the favored minimally invasive method for extracting foreign bodies from the knee joint, especially from its deeper and less accessible regions. Utilizing pre-operative radiological imaging enhances understanding of the anatomical placement, facilitates surgical orientation, and reduces operation time. A keen sense of suspicion and thorough history-taking are crucial in achieving an accurate diagnosis.

Determination of the Perpetrator-Victim Position in a Case of Severe Traumatic Brain Injury due to a Less-Lethal Weapon Projectile, Based on Brain Injuries

Less-lethal (or non-lethal) weapons cause lethal and non-lethal injuries; this depends on many factors, including the shot distance and the modifications made to the operation of the weapon and the projectiles. This type of weapon has a similar shape to a firearm, shares the same physical and chemical operating principle and uses the combustion of a chemical substance to eject the projectile. In technical terms, the only difference is the projectile. Currently with the changes in weapons and projectiles, it is difficult to make a correlation. Just like lethal firearm projectiles and due to their operation, they leave macroscopic gunshot residues such as powder tattooing or soot deposition, only occasionally a contusion ring. In addition, there is a variety in the appearance of the entrance wounds. Therefore, it is very important to process the scene and carefully dissect the external wound and the surrounding area and, if possible, the recovery of the projectile. We present a case where a non-penetrating superficial injury to the skull produced trauma consistent with a coup contrecoup brain injury, which allows us to identify the perpetrator-victim position.

Surgical Management of Penetrating Carotid Artery Injury: Preoperative Level of Consciousness Does Matter.

The optimal surgical management of penetrating carotid artery injuries (PCAI) remains controversial. This study aimed to examine the association between operative techniques for PCAI and the incidence of stroke. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program (2016-2021) database. We included patients (≥16 years old) with severe penetrating injuries to the common or internal carotid arteries (CCA/ICA) who underwent one of the following operative procedures: primary suture repair, ligation, and arterial reconstruction with a graft. Multivariate logistic regression analysis with cluster-adjusted robust standard errors was performed to estimate the adjusted odds ratio (AOR) for postoperative stroke stratified by the initial Glasgow Coma Scale (GCS). A total of 429 patients were included (329 underwent primary suture repair, 82 underwent ligation, and 81 underwent arterial reconstruction with a graft). The median age was 31 years (interquartile range [IQR]: 24-43) and median GCS on arrival was 11 (IQR: 3-15). On multivariate analysis after adjusting for potential confounders, ligation of CCA/ICA was significantly associated with increased odds of stroke in patients with initial GCS ≥9 (AOR: 4.40, 95% confidence interval [CI]: 1.16-16.58, p=0.029), whereas there was no significant association in patients with GCS <9 (AOR: 0.77, 95% CI: 0.28-2.11, p=0.37). No significant association was identified between arterial reconstruction with a graft and stroke, irrespective of the initial GCS. The study findings suggest that the preoperative level of consciousness may help in planning operative strategies for PCAI. In patients with an initial GCS ≥ 9, definitive repair of the CCA/ICA, including arterial reconstruction with a graft, should be pursued instead of ligation.