Shot Wounds Research Articles

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct to Damage Control Surgery for Combat Trauma: A Case Report of the First REBOA Placed in Afghanistan

This case report details a trauma case – transpelvic gun shot wound with hemorrhagic shock- treated with REBOA as an adjunct to resuscitation. This is the fi rst reported case of REBOA in Afghanistan at the Role 3 Multinational Medical Unit in Southern Afghanistan.

Renal fistulae: different aetiologies, similar management

Iatrogenic renocolic fistulae, although have been described in literature, is a rare clinical complication. Recently its incidence is on rise due to advent of minimally invasive surgery and percutaneous surgery...

The utility of presacral drainage in penetrating rectal injuries in adult and pediatric patients

BackgroundWith changing weaponry associated with injuries in civilian trauma, there is no clinical census on the utility of presacral drainage (PSD) in penetrating rectal injuries (PRIs), particularly in pediatric patients. MethodsPatients with PRI from July 2004-June 2014 treated at two free-standing children's hospitals and two adult level 1 trauma centers were compared by age (pediatric patients ≤16 years) and PSD. A stratified analysis was performed based on age. The primary outcome was pelvic/presacral abscess. ResultsWe identified 81 patients with PRI; 19 pediatric, 62 adult. Forty patients had PSD; only three pediatric patients had a drain. Adult patients were more likely to have sustained gunshot wounds (84%), whereas pediatric patients were more likely to sustain impalement injuries (59%). Pediatric patients were more likely to have distal extraperitoneal injuries (56% versus 27% in adults, P = 0.03). PSD was more common in adult patients (59% versus 14%, P = 0.0004), African-Americans (71% versus 11% Caucasian, P < 0.01), and those sustaining gun shot wounds (63% versus 18% impalement, P < 0.01); only race remained significant in stratified analysis for both adult and pediatric patients. There were three cases of pelvic/presacral abscess, all in the adult patients (P = 0.31); one patient with PSD and two without PSD (P = 0.58). In stratified analysis, there were no differences in any infectious complication between those with and without PSD. ConclusionsPelvic/presacral abscess is a rare complication of PRI, especially in pediatric patients. PSD is not associated with decreased rates of infectious complications and may not be necessary in the treatment of PRI.

Nickel and copper residues in meat from wild artiodactyls hunted with nickel-plated non-lead rifle bullets

A nickel (Ni)-plated copper-solid bullet type released up to 93 μg Ni /10 g bullet mass when immersed into meat juice for 7 days (to simulate fragments remaining in venison). A non-nickel-plated counterpart of identical construction released no Ni, but up to 250 μg copper. During thermal processing of pork cubes with embedded bullets, an average of 2.8 and up to 4.3 (maximum) μg Ni were released from the Ni-plated bullet to the surrounding meat. Average nickel and copper content in meat samples (taken in 2–3 cm distance from the shot wounds) from 30 roe deer (Capreolus capreolus) and 3 sika deer (Cervus nippon) killed with nickel-plated copper bullets did not differ significantly from those in controls (roe deer haunch). Contamination scenarios would Cu and Ni contents per portion increase moderately by 20 and 3.3 μg, respectively. In order to limit alimentary Ni uptake, the technological need for Ni-plating of bullets should be carefully evaluated.

Bullet Proof - Previous Coronary Artery Surgery Preventing Tamponade in a Gun Shot Wound to the Chest

Purpose: We present the case and pertinent radiology of a 74-year-old male with a history of coronary artery bypass grafting who sustained a self-inflicted gun shot wound to his anterior chest from a 0.22 calibre rifle loaded with bird shot. The injury was sustained several hours prior to presentation, with no adverse haemodynamics. CT scan demonstrated multiple pellets related to the antero-inferior aspect of the right ventricle, and a pseudoaneurysm, likely contained by pericardial adhesions from previous surgery. Hepatic segments 2 and 3 were lacerated, and there were pellets surrounding the descending aorta. He underwent laparotomy and wedge resection of segments 2 and 3 of the liver and repair of the diaphragm, however, the injury to the right ventricle was managed conservatively. The patient was referred to a psychiatric service following an uneventful admission. Conclusion: We believe that intrapericardial adhesions from previous cardiac surgery prevented this patient from developing a large volume haemopericardium, tamponade, and perhaps death. Of course, had a larger bullet size or calibre entered his chest, he would have been unlikely to survive.

Comparison of analgesic efficacy of levobupivacaine, levobupivacaine and clonidine, and levobupivacaine and dexmedetomidine in wound infiltration technique for abdominal surgeries: A prospective randomized controlled study

Background: This study was designed to evaluate the postoperative analgesic efficacy of levobupivacaine (L) alone and its combination with clonidine (C) or dexmedetomidine (D) in wound infiltration technique for abdominal surgeries. Materials and Methods: After ethical committee approval, a double-blind randomized controlled study was conducted on 90 patients (power of study 80%), physical status American Society of Anesthesiologists Grade I and II, aged 18–60 years scheduled for abdominal surgeries over 1 year duration. A standard general anesthetic technique was used. Patients were randomly allocated into three groups, by computer-generated random number table. Patients received wound infiltration during wound closure. Group L received 29 ml of 0.25% levobupivacaine plus 1 ml 0.9% normal saline, Group LC received 29 ml of 0.25% levobupivacaine with 1 ml (3 mcg/kg) clonidine, and Group LD received 29 ml of 0.25% levobupivacaine with 1 ml (2 mcg/kg) dexmedetomidine. Postoperative rescue analgesia was provided with injection tramadol. Statistical analysis for duration of analgesia was determined by one-way analysis of variance and side effects by Chi-square test. Results: The total duration of analgesia in LD group was 23.4 h, when compared to LC group 20.9 h and L group 11.65 h (P = 0.0001) with excellent to good quality of analgesia in adjuvant group (P < 0.001) and incidence of minimal side effects such as sedation, nausea, and vomiting. Conclusion: Clonidine and dexmedetomidine were the effective adjuvants to levobupivacaine for single shot wound infiltration analgesic technique; however, dexmedetomidine was found to be superior to clonidine.

DETERMINATION OF TYPE AND MARK OF PROJECTILES BY METHOD OF X-RAY FLUORESCENCE SPECTRAL ANALYSIS IN THE STUDY OF PNEUMATICALLY SHOT INJURIOUS TO SOME CLOTHING MATERIALS

The X-ray fluorescence spectral qualitative and quantitative analyses were performed for the elemental composition of 4 marks of bullets for pneumatic weapon of home and foreign production, and also for imitators of common clothing materials camouflage fabric and cotton knitwear. It is determined that lead bullets for pneumatic weapons are capable to introduce some elements of their composition, which are inherent in one or another mark of bullets, to the area of damage on certain clothing materials, in particular, camouflage fabric and cotton knitwear. This expands the possibilities of forensic medical examination when dealing with a problem of determining the type and mark of a bullet or of a small group of bullets similar in their elemental composition, due to which the pneumatical shot injuries of examined objects took place.

WHO ARE OUR ‘CODE-RED’ KIDS? – A URBAN MAJOR TRAUMA CENTRE'S EXPERIENCE OF MAJOR HAEMORRHAGE IN INJURED CHILDREN

Objectives & BackgroundMajor trauma in children, while being relatively uncommon, is still a principal cause of preventable death with severe haemorrhage being one of the main responsible reasons. ‘Major haemorrhage...

‘WOMEN, COME AND ROAST YOUR OWN RAM!’: RECOLLECTIONS ON MAU-MAU GENERAL CHUI WA MARARO (1927–1956)

Little has been written about General Chui (1927–1956), the unique and charismatic fighter during Kenya’s war of independence, yet he worked hand-in-hand with Field Marshall Dedan Kimathi Wachiuri, the overall commander of Kenya Land and Freedom Army (KLFA), also called Mau- Mau fighters. Kibara wa Mararo, later General Chui, who came from Meiria residence, Mugaya state, Kamuiru village of Mutira location, Ndia Division of the present day Kirinyaga County, Kenya, became a household name, and a hero to the then marginalised African populace, after the famous Mbaara ya Rui Ruiru (battle of river Ruiru). In this war of 1953, which took place on the border of Nyeri district (which was elevated to a County in 2010) and the old Embu district (which constitutes Kirinyaga and Embu counties), Kibara wa Mararo disguised himself as a regional inspector of the police. Clad in full colonial army uniform, he was able to trick some security officers and the loyalists who were derogatorily called Tukonia (empty sacks). This made them quickly rush to meet their boss. In a twinkle of an eye, the coded language (kebunoko) was sounded calling the Mau-Mau fighters who eventually turned their guns on the officers thereby wiping them clean in one blow. It is from there that the Mau-Mau high command declared him an army general. Since then, he became known as General Chui – ‘Chui’ meaning the sharp leopard. As Kenya marked its 50 years of independence (1963–2013), with pomp and colour, the sacrificial role of General Chui re-appears as one wonders: how was such a military genius finally ambushed at River Rwamuthambi’s Riakiania mushy cave and subsequently shot dead by the colonial forces? Did the surrendering Mau-Mau soldiers betray him, General Magazine and the other fighters who died of gun shot wounds at the Riakiania scene? Again, what were his political ideals? In its methodology, the article begins by retracing the nature of Mau-Mau movement citing the key issues that possibly caused it. It then moves on to chronicle General Chui wa Mararo as a case study. The materials in this presentation are largely gathered through interviews and archival sources.

Management of gun shot injury in a tertiary hospital

Introduction: Gun shot injury is an uncommon surgical emergency . A timely and multidisciplinary management by surgical team is an essential factor in decreasing mortality and morbidity . This study highlights the multidisciplinary management of gun shot injury.Methodology: Bir hospital is a postgraduate teaching hospital under National Academy of Medical Sciences and tertiary referral center in Kathmandu. A prospective cohort study of gunshot injury was conducted during Septemeber 2015 and early outcome analysis was done.Results: There were thirteen cases of gunshot wound. The mean age of casualty was 31 years and all were male.Injury Number (n) Intervention Outcome Large intestine 3 Laparotomy Ileostomy/wound infection Perineum 1 Exploration/Debridement Loop ileostomy Bone- fracture 3 Traction/Enternal fixation/ Open reduction Internal Fixation Vertebra 1 Right hip power 3/5 Vascular- AV fistula 1 stenting Referred Brachial plexus 1 Sensory/motor deficit Neck 2 Exploration Marginal mandibular nerve palsy Elbow 1 Debridement/Split thickness skin graftThere were no mortality and one case was referred.Discussion: With the multidisciplinary team approach, all the gunshot injury cases were managed with good outcome. The timely intervention by a surgical team is an essential factor for proper management of gun shot injury.

P.117 Delayed contralateral presentation of a carotid cavernous fistula following trauma

Background: We present a rare case of a left-sided carotid cavernous fistula (CCF) that presented 15 months post initial trauma with right-sided ophthalmic signs and symptoms. Highlighted is a contralateral endovascular approach to treating this traumatic CCF. Methods: Described is a case of a left-sided CCF caused by a self-inflicted gun shot wound to the head that was initially treated conservatively by neurosurgery and opthomology. The patient presented 15 months later with headache, acute right-sided periorbital swelling, severe right eye and facial pain. Results: Angiography confirmed the presence of a left-sided CCF with preferential drainage into the right cavernous sinus and right superior ophthalmic vein. The left internal carotid artery (ICA) was shown to be narrow and irregular. Multiple attempts to navigate the micro catheter through the vessel were unsuccessful. Instead, the fistula was embolized using a contralateral approach through the right internal carotid artery and across the anterior communicating artery. Imaging post-operatively confirmed successful occlusion of the CCF. Conclusions: This case is a rare example of a left-sided ICA occlusion secondary to trauma presenting 15 months after the initial injury with right-sided ophthalmic signs and symptoms. It is also one of only a few in the literature that describe successful treatment of traumatic CCF through a contralateral approach.

Classification of airgun shot injuries

Based on the analysis of airgun shot trauma by materials some Bureau of Forensic Medicine of Ukraine for 2006- 2015, using the previously proposed terminology and conceptual apparatus first developed unified classification containing 15th bases required for comprehensive response of airgun shot injuries. This classification is used for the study, description, diagnostics and statistical processing of airgun shot injuries as forensic doctors and clinicians.&#x0D; Damage caused to a person from modern airguns, currently is not well understood, particularly not classified. Analysis of airgun shot trauma showed that forensic doctors in research and in carrying out examinations of living persons and dead bodies, as well as clinicians in the care of the wounded from the pneumatic weapon need classification of airgun shot injuries which would be determined by their comprehensive features and would unify exploration, description and evaluation of the damage, in particular in formulation of diagnosis and reporting.&#x0D; Having studied and analyzed data from 98 of the Сonclusions of experts and Acts of the forensic medical examination of living persons (76) and bodies (22) with damage caused by pneumatic weapons made in some Bureau of Forensic Medicine of Ukraine in 2006-2015 as well as scientific works of domestic and foreign authors, devoted to the study of the problem of forensic (37 sources), monolingual, spelling and terminology dictionaries. Airgun shot injuries were divided according to the following fifteen principles: the form of the projectile, the action product shot, location, type of injuries, type of damaged tissues and organs of the body, the number of injuries, the degree of penetration into the body tissues, relative to the external environment, relative of the body, with respect to cavi- ties of the body, relative parts of the body, view of the wound channel, the severity of the injuries, the outcome of injuries, the distance of the shot.&#x0D; Conclusions: 1. The proposed classification will promote unified approach to forensic doctors during the study of airgun shot injuries and performing examinations of living persons and dead bodies of clinicians in the diagnosis and treatment of victims, lawyers in assessing the findings of forensic experts. 2. It is considered appropriate to mention in the accounting documents airgun damage separately. 3. Further systematization of airgun shot injuries will provide the necessary methodological bases for their research, which will contribute to a deeper study of this problem.

A study on medico-legal and clinical aspects of congenital sternal foramina

Sternal foramen is a congenital round bony defect present in the body of sternum which results from incomplete union of the sternal ossification centres. Usually the defect is asymptomatic and only be detected by CT scan. But at times, it may be misinterpreted as gun shot or stab wound. In clinical practice, sudden unexpected death may take place during sternal puncture and biopsy as a result of cardiac puncture and tamponade. The present study was carried out by choosing 96 dry sternal bones which were used as a teaching material in the Department of Forensic medicine and Anatomy, CCM Medical College, Durg, Chhattisgarh and MIMER Medical College, Talegaon, Pune, Maharashtra. These sternal bones were examined for the presence of sternal foramen and it was found in 4.1% of cases. It is important for medical practitioners, radiologists and acupunturists to have a concrete knowledge of sternal anomalies before doing any procedures to avoid complications.

Percutaneous Endoscopic Gastrostomy feeding of a patient with Gun Shot Wounds: Nursing Interventions and Prevention of Complications

Percutaneous Endoscopic Gastrostomy feeding of a patient with Gun Shot Wounds: Nursing Interventions and Prevention of Complications

FATAL AIRGUN SHOT TRAUMA: STRUCTURAL ANALYSIS AND MORPHOLOGICAL FEATURES INJURIES

Completed structural analysis of fatal airgun shot injuries and studied the morphological features of damage of modern powerful airguns caliber 4.5 mm. It was determined that the vast majority of the deaths were homicides and suicides. The projectiles who shot from a distance of up to 10 meters have a specific kinetic energy sufficient to cause fatal wounds penetrating mainly diametric head and chest bone fractures and injuryes a brain, heart and other internal organs or large blood vessels. Some features of the damage caused by the action of a powerful airguns are - formation of muzzle imprint when shot at, the penetrtoin effect of the shell when entering the body, even in the presence of a multi-layer clothing, internal ricochet projectile when entering bone and changing the direction of the wound channel, the migration of the projectile through the blood vessels.

Gun Shot Wound to Left Chest with "Transmediastinal" Trajectory. A Case Report and Review

C l i n M e d International Library Citation: Hobbs RD, Marks JA, Kucharczuk JC, Reilly PM (2015) Gun Shot Wound to Left Chest with “Transmediastinal” Trajectory. A Case Report and Review. Trauma Cases Rev 1:009 Received: August 11, 2015: Accepted: September 16, 2015: Published: September 18, 2015 Copyright: © 2015 Hobbs RD. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hobbs et al. Trauma Cases Rev 2015, 1:1 ISSN: 2469-5777

Gun shot wounds to the head and neck region among trauma patients – 5-year experience at Legacy Emanuel Medical Center

Gun shot wounds to the head and neck region among trauma patients – 5-year experience at Legacy Emanuel Medical Center

A Case of a Bullet Penetrating the Esophagus

Purpose: We present a case of a bullet visualized during endoscopy after gun shot wound in which no surgical or endoscopic intervention was needed for a good outcome. Results: Patient is a 21 year old female with recent gun shot injury who came to emergency room complaining of epigastric pain. One month ago, she presented with gun shot wounds and was found to have three bullet fragments in her body-two fragments in her left leg and one large fragment between the esophagus and aorta without extravasation from heart, aorta or great vessel. Barium swallow study did not show any esophageal injury at the time. She had multiple medical complications during that hospitalization, including pneumomediastinum, right hemothorax and pneumothorax, and posterior mediastinal hematoma. Surgical removal of this bullet fragment was not done due to difficult positioning and risk associated with operative intervention. During the most recent admission, the patient presented with epigastric pain and nausea that became progressively worse the last few days. Swallowing exacerbated the pain. She denied difficulty protecting her airway, dysphagia, emesis, hematemesis, or hemoptysis. Initial CT scan was concerning for shift in position of bullet compared to previous imaging. Gastroenterology team was consulted, as it was difficult to discern if the bullet penetrated the esophagus. EGD was performed and the bullet was seen embedded in mucosa of the lower esophagus. Gastrograffin esophagram did not show any contrast extravasation. Aortogram showed no focal aortic or arterial injury. The surgery team discharged the patient without surgical intervention, as she was tolerating a diet and did not have evidence of vasculature injury. Few weeks later, plain films showed the bullet having migrated into the small intestine. One week later, the bullet was in the left colon. EGD and flexible sigmoidoscopy were performed without retained bullet. Esophageal mucosa was completely normal without any abnormalities. Conclusion: This is a case of a bullet that fully penetrated the esophagus over time without any complications. No surgical or endoscopic intervention was required, with the esophageal mucosa healing completely on its own.Figure 1

Cardiogenic oscillation induced ventilator autotriggering

AbstractCardiogenic oscillation during mechanical ventilation can auto-trigger the ventilator resembling patient initiated breadth. This gives a false sense of intact respiratory drive and determination brain death, even if other tests are positive, is not appropriate in such a situation. It will prolong the ICU stay and confound the brain-death determination. In this case report, we describe a 35 year old man who was brought to the hospital after many hours of critical delay following multiple gun shot injuries. The patient suffered a cardiac arrest while on the way from another hospital. After an emergency laparotomy, patient was shifted to Intensive Care Unit (ICU) with Glasgow Coma Scale (GCS) score of E1VTM1 and was mechanically ventilated. Despite absence of brainstem reflexes, the ventilator continued to be triggered on continuous positive airway pressure (CPAP) mode and the patient maintained normal oxygen saturation and acceptable levels of carbon dioxide. An apnoea test confirmed absent respiratory drive. Ventilatory waveform graph analysis, revealed cardiogenic oscillation as the cause for autotrigerring.

The orthopaedic experience of Kasr Al Ainy Hospitals in the Egyptian revolution.

25 January 2011 marks the onset of the Egyptian revolution. Causalities were estimated to be at least 846 moralities and 6000 injuries. The purpose of this study is to document the orthopaedic injuries coming to the tertiary center of Cairo University Hospitals (Kasr Al Ainy) during the climax of the Egyptian revolution and the lessons learnt. We retrospectively reviewed all hospital admissions in the period of 28 January 2011 till 4th February 2011 due to injuries related to the revolution. Total number of patients examined by the orthopaedic residents and staff members in the emergency room during that period was 553 patients. A total of 110 patients were admitted to the orthopaedic department. Various injuries were encountered. The most common were gun shot injuries (45 cases), followed by falls (28 cases), road traffic accidents (26) and trauma by blunt objects (11 cases). Overall 121 operative procedures were conducted in the operative theater by our residents and staff members. Fractures of the femur were the most common fractures (27 cases) followed by forearm fractures (13 cases). Limitations were the availability of a limited variety of orthopaedic implants. We believe that tertiary centers should be prepared for mass causalities. A variety of orthopaedic implants should be within reach and that personnel should be trained to work under stressful environments with a well laid disaster management plan.