Shotgun Blasts Research Articles

The role of co-administration of damage control surgery and vacuum-assisted closure in the treatment of perineal wounds.

Perineal wounds caused by high-kinetic-energy shotgun blasts have a high mortality risk because they are often accompanied by injuries of the anus, rectum, genitourinary system, and extremities. Mortality often results from hemorrhage in the early stage and from multiple organ failure caused by sepsis in the late stage. The primary step in the treatment of patients presenting with perineal wound and hemodynamic instability caused by severe hemorrhage is to control hemorrhage and contamination using damage control surgery. After achieving hemodynamic stability, vacuum-assisted closure can be used to reduce the risks of infection and sepsis. In this report, we present a case who had a perineal wound caused by a mine blast and was successfully treated by damage control surgery and vacuum-assisted closure.

Preparing for and Minimizing Risks of an Active Shooter

Preparing for and Minimizing Risks of an Active Shooter

Truman Capote and the legacy of In cold blood

Ralph F. Voss was a high school junior in Plainville, Kansas in mid-November of 1959 when members of the Herbert Clutter family were murdered in Holcomb, Kansas, by four shotgun blasts that, all told, ended six human lives, an unimaginable horror in a quiet farm community during the Eisenhower years. No one in Kansas or elsewhere could then have foreseen the emergence of Capote's book-which has never gone out of print, has twice been made into a major motion picture, remains required reading in criminology, American Studies, sociology, and English classes, and has been the source of two recent biographical films. Voss examines Capote and In Cold Blood from many perspectives, not only as the crowning achievement of Capote's career, but also as a story in itself, focusing on Capote's artfully composed text, his extravagant claims for it as reportage, and its larger status in American popular culture. Voss argues that Capote's publication of In Cold Blood in 1966 forever transcended his reputation as a first-rate stylist but second-rate writer of Southern fiction; that In Cold Blood actually is a gothic a sophisticated culmination of Capote's artistic development and interest in lurid regionalism, but one that nonetheless eclipsed him both personally and artistically. He also explores Capote's famous claim that he created a genre called the non-fiction novel, and its status as a foundational work of true crime writing as practiced by authors ranging from Tom Wolfe and Norman Mailer to James Ellroy, Joe McGinniss, and John Berendt. Voss also examines Capote's artful manipulation of the story's facts and circumstances: his masking of crucial homoerotic elements to enhance its marketability; his need for the killers to remain alive long enough to get the story, and then his need for them to die so that he could complete it; and Capote's style, his shaping of the narrative, and his selection of details-why it served him to include this and not that, and the effects of such choices-all despite confident declarations that every word is true. Though it's been nearly 50 years since the Clutter murders and far more gruesome crimes have been documented, In Cold Blood continues to resonate deeply in popular culture. Beyond questions of artistic selection and claims of truth, beyond questions about capital punishment and Capote's own post-publication dissolution, In Cold Blood's ongoing relevance stems, argues Voss, from its unmatched role as a touchstone for enduring issues of truth, exploitation, victimization, and the power of narrative.

An Update on Facial Transplantation Cases Performed between 2005 and 2010

Since 2005, 13 facial allotransplantation cases have been performed worldwide. The major indications for these facial allotransplantations were neurofibromatosis and trauma injuries, including animal bites, burns, falls, and shotgun blasts. An analysis of 13 facial transplantation cases was performed by reviewing the anatomical details, microsurgical techniques, and functional outcomes according to the follow-up information based on the literature, meeting presentations, and media reports. The male-to-female ratio was 11:2. Two male patients died at 2 months and 2 years, respectively, after transplantation because of transplant- and infection-related problems. Eleven face transplant recipients are alive. The composite tissue allotransplants included cutaneous, myocutaneous, and osteomyocutaneous components. Most of these facial allotransplants were partial, one was nearly total, and two were announced as total face transplantations. This report provides a useful overview of the technical aspects of face transplantation; however, the reports on long-term functional and aesthetic outcomes will help to define the future of face transplantation.

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.

Management of maxillofacial problems in self-inflicted rifle wounds.

Severe gunshot wounds to the face, produced by high-velocity rifles or shotgun blasts, present a formidable challenge to reconstructive surgeons. In this study, the results of 14 cases with gunshot wounded faces caused by fire from rifles are presented, and the principles of the management of those victims were determined. These patients had attempted to commit suicide and placed the muzzles of the rifles beneath their chins. The ages of the patients ranged from 20 to 24 years, with a mean age of 22 years. These wounds were caused by close-range gunshots (<10 cm), and the missiles had high velocity (more than 800 m/second). All patients had wounds in their submental triangle areas. The exit sites of the missiles differed among patients. All exit wounds were in the angle limited by the deviation from the gun-barrel axis. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the fractures were reduced and stabilized appropriately. Large bony defects were treated by bone grafting, and all soft tissue lesions were closed in layers. The entrance and exit sites were covered primarily after thorough debridement except one case whose defect was reconstructed with bilateral sternocleidomastoid (SCM) flaps, one for submental skin and the other for the mouth floor. Intraoral soft tissues were then repaired by primary closure, tongue flaps, or SCM flaps in case they were necessary. Free tissue transfers were not required for treatment of secondary soft-tissue problems. Resolution of tissue edema, softening of scars in time, and insertion of bone graft may improve the deformity significantly. The initial anatomic reconstruction of the existing bone skeleton and the maximal use of regional tissue for cutaneous reconstruction provide an esthetic appearance that can never be duplicated by secondary reconstruction.

Management of shotgun injuries to the pelvis and lower genitourinary system

Objectives. Shotgun injuries are rare, with the extent of injury best determined at time of surgical exploration. There are no defined workup or management guidelines for patients with shotgun injuries to the genitourinary system. Injuries are usually treated on an individual basis. This study was conducted to determine the management and extent of genitourinary tract injuries in 10 patients with shotgun injuries to the pelvis during a 6-year interval. Methods. Between September 1990 and December 1996, 140 patients were treated for firearm injuries to the lower genitourinary tract, of which 10 were secondary to shotgun blasts. We performed a retrospective hospital and clinic chart review and telephone interview to assess organs injured, initial treatment, follow-up surgeries, mortality, and erectile function. Results. Mean patient age was 20 years at the time of the injury. The mean follow-up was 4 years (range 1 to 7). Two patients died, both with major vascular injuries, one in the operating room and the other 1 week later from sepsis. Eight patients underwent radiographic examinations (1 intravenous urogram and 7 urethrocystograms). The bladder was injured in 5 patients, 2 with concomitant complete posterior urethral transection. Of the 5 patients without bladder injury, one had an incomplete penile urethral injury and one had a complete bulbar urethral transection. The initial management consisted of repairing nongenitourinary injuries in 8 cases (80%), most commonly involving injuries to the rectum and small bowel. All patients were treated operatively, including 8 who required laparotomy and 4 who required suprapubic cystotomy. A total of four urethral injuries were noted. Subsequent reconstructive surgeries included two urethroplasties and one permanent supravesical diversion for 3 patients with extensive urethral loss. Erectile dysfunction was present in 3 of 6 patients available for telephone interview. Conclusions. Shotgun injuries involving the lower genitourinary tract are associated with significant soft tissue injury and morbidity. Death usually results from major associated vascular injuries. All hemodynamically stable patients should undergo retrograde urethrograms and cystograms to evaluate possible urethral and bladder injuries. Open primary repair should be attempted for distal urethral, testicular, and corporal injuries. Delayed repair with staged urethral reconstruction should be reserved for patients with extensive loss of urethral tissue. Impotence is common in patients with extensive perineal injuries.

Comparison of Contact Shotgun Wounds of the Head Produced by Different Gauge Shotguns

A series of 89 contact shotgun wounds of the head were evaluated to compare the extent of wounding produced by different gauge shotguns. Twelve gauge shotguns were the most common, accounting for 69% of the cases, followed by 20 gauge (18%), .410 caliber (10%), and 16 gauge (3%). The mouth was the most common entry site, used in 62% of cases. Comparison of contact intraoral shotgun wounds revealed statistically significant differences between 12 gauge and 20 gauge wounds. Whereas the extent of internal destruction was similar with both gauges, intraoral 12 gauge shotgun wounds caused bursting of the head with lacerations of the face, forehead, and scalp in 74% of cases, while only 9% of 20 gauge wounds produced a similar extent of external disruption. The external head remained fully intact in 55% of 20 gauge intraoral wounds. To account for the threshold effect for head bursting between 20 gauge and 12 gauge shotgun blasts, commercial shotshell and reloading data were analyzed. While there was considerable overlap between the two gauges, a common 12 gauge load would generate 50% more kinetic energy and 40% greater volume of gas than a common 20 gauge load. Comparison of shotgun blasts at entry sites outside of the mouth showed similar differences. Wounds from .410 shotguns were similar to those from 20 gauge weapons, and 16 gauge shotguns produced wounds intermediate between 20 and 12 gauge.

EARLY EXCHANGE INTRAMEDULLARY NAILING OF DISTAL FEMORAL FRACTURES WITH VASCULAR INJURY INITIALLY STABILIZED WITH EXTERNAL FIXATION

Fracture of the femur with accompanying arterial injury represents approximately 1% of all femoral fractures. Controversy exists regarding the choice of fixation and the sequence of fixation and vascular repair. We report on the treatment of six patients with seven distal femoral fractures and angiographically documented arterial injuries treated over a 20-month period. The treatment protocol consisted of angiography followed by provisional external fixation and early primary exchange to an intramedullary nail. Five of the seven fractures were open. Three fractures were caused by blunt trauma, and four were secondary to shotgun blasts. Average follow-up was 12 months (range, 6-25 months). All fractures healed with an average time to union of 25 weeks. There were no complications related to the vascular repair. One case of an acute deep infection resolved after debridement and placement of polymethylmethacrylate cement beads impregnated with antibiotics and a course of intravenous antibiotics. All patients returned to their previous levels of activity. Based on the results of our experience with a small group of patients, we feel that this treatment protocol will prove to be a safe and efficient method of management of these difficult injuries.

Shotgun wounds of the limbs

Shotgun blasts may cause devastating injuries in civilian trauma practice. We have reviewed 23 consecutive patients with 28 deliberate shotgun wounds to limbs treated over a 4-year period. Wounds were categorized using the Red Cross wound classification. Twenty wounds were high-energy transfer grade 2 and 3 injuries: eight involved only the soft tissues (five category 2ST, three category 3ST), 10 wounds involved fractures (two category 2F, seven category 3F, one category 3VF), and three wounds involved major vessel injury (two category 3V, one category 3VF). Category 2ST and 3ST wounds were managed successfully with thorough wound excision of divitalized tissue, fasciotomy, and early wound closure. The more complex category 3F, 3V and 3VF wounds required a multidisciplinary approach to their management. Three lower limbs (category 3F, 3V, and 3VF wounds) with associated major nerve injury were amputated at the first operation; there were no cases of secondary amputation. Of the salvaged limbs, those with category 3F injury at or below the level of the elbow or knee had poor functional results.

The Management of Large Soft-tissue Defects following Close-range Shotgun Injury

Large soft-tissue defects following close-range shotgun blasts remain a major technical challenge to trauma surgeons. During the period 1980 through 1988, 43 patients who survived greater than 48 hours following this injury were managed in our center. The locations of their soft-tissue defects were: extremity, 22; abdomen/chest, 18; and head/neck, three. All patients underwent immediate surgical exploration and wide debridement of all devitalized tissue along with repair of associated injuries. Management included mandatory frequent dressing changes, debridement, irrigation in the operating room, and the perioperative administration of broad-spectrum antibiotics. Four patients whose abdominal wall defects could not be initially closed had temporary placement of rayon cloth to prevent evisceration. Overall, four patients underwent delayed primary closure, eight were covered with split-thickness skin grafts, nine had closure with myocutaneous flaps, and 19 closed by secondary intent. Two patients, who were transferred to us following initial management, developed wound sepsis due to inadequate debridement and both eventually required amputation as did one patient who developed early myonecrosis following lengthy arterial repair. Frequent operative dressing changes, adequate debridement, and irrigation minimize sepsis following close-range shotgun blasts and should be the treatment of choice for this devastating injury. Techniques of wound closure need to be individualized to the particular situation.

Popliteal Vascular Trauma

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.

Characteristics of pediatric firearm fatalities

An increase in the awareness of the problem of gunshot fatalities in children has occurred nationwide over the last year. Unintentional firearm deaths are more common among children and young adults. These deaths may be addressed by preventive measures beyond those available for pediatric firearm suicide and homicide. This study focuses on the incidence of fatal gunshot injuries in children under 16 years of age during the years 1979 through 1987 in our state. Over the past 9 years 132 children (0 to 16 years) were shot and killed as a result of firearm injuries (M:F ratio, 3:1). No difference in absolute number in racial distribution existed. Deaths were classified as homicide, 61 (46%); accidental, 33 (25%); suicide, 29 (22%); undetermined, 7 (5%); and other, 2 (1.5%). Over 70% of these fatal injuries occurred in the home environment. Types of weapons involved included handguns (48%), shotguns (22%), rifles (17%), unspecified weapon (12%), and air rifle (1%). In a large number of cases, guns were found in the home unsecured. The perpetrator was known by the victim in 64 instances, while unknown in 27. Thirty-nine self-inflicted wounds and two shotgun blasts in the line of fire accounted for the remaining deaths. The most common anatomical injury and ultimate cause of death was cranial central nervous system (CNS) (62%), followed by chest/mediastinum (20%), abdomen (10%), and other (8%). A child who has sustained a firearm injury is more likely to know the perpetrator, be killed in the home by a readily available unsecured firearm, and die from severe head injury.

Raiders of the Lost Art: Using the "Painted Word" in Writing

I recall an oddity from a high-school English textbook, somewhere along the way, perhaps in my junior year. There, in repeated profusion, were periodic shotgun blasts of famous paintings which cropped up as great drifts of colorful deadwood, as I now understand, to show the young reader/ writer just what those brash sorts called painters were up to while Thoreau was busy with CivilDisobedience and Steinbeck with Lennie and George. I never understood the connection, for indeed one was never officially made. Our teacher would regularly bypass these intrusions and press us on to the things she considered more worthwhile. Yet now it all seems so connected, so purposeful for those works to be taking up space in a book dealing with literature. While I do not subscribe to the premise that English teachers are something of the last bastion of our culture to surrender to

Popliteal Artery Trauma: Update and Recent Advances in Management

Management of vascular trauma has been standardized in the past two decades with a significant increase in limb salvage, but trauma to the popliteal artery still remains a challenge. A seven-year experience at San Bernardino County Medical Center was comprised of 20 popliteal artery injuries in 19 patients. Thirteen injuries (65%) were from blunt trauma, four injuries (20%) were from gunshot wounds, two injuries (10%) were from close-range shotgun blasts, and one (5%) was from a stab wound. Limb salvage was 100%. Liberal use of vein interposition grafts, routine intraoperative postreconstructive arteriogram, recognition of compartmental hypertension, and performance of fasciotomy were important steps taken to ensure a high limb salvage rate. Our standard technique at this time consists of repair of the artery with simultaneous repair of the dislocated knee and internal fixation of fractures.

Intra-abdominal vascular injury secondary to penetrating trauma.

There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

Peripheral vascular trauma from close-range shotgun injuries.

This report summarizes an eight-year experience (1976 to 1983) with 49 close-range shotgun blasts with associated major vascular injuries seen in a large urban hospital. Injuries to the upper extremity (40%), lower extremity (56%), and neck (4%) were seen. A high frequency of associated deep venous injury (82%), nerve injury (37%), fracture (33%), massive soft-tissue loss (43%), and compartmental hypertension (39%) was observed. There were no deaths in this series, and the limb salvage rate was 96%. Neither patient with multiple carotid artery injuries suffered a neurologic deficit. We attribute our success in the management of these complex injuries to rapid fracture immobilization, early and aggressive use of fasciotomy, adequate débridement of devitalized tissue, repair of deep venous injuries, arterial repair with autogenous tissue, and extra-anatomic bypass grafting in selected cases.

Case Involving Differentiation of Deer and Human Bone Fragments

In a recent Louisiana forensic anthropology case, it was necessary to attempt species identification of six small bone fragments. The primary concern was whether or not they matched the fractured humerus of a woman killed by two shotgun blasts and then disposed of in the Mississippi River. These tiny fragments were recovered by law enforcement officers inside a jeep pickup and at the gas station where the vehicle had been cleaned. The police suspect claimed that these fragments were from a deer that he had recently killed. The small size of the pieces precluded positive recognition of human versus nonhuman origin based upon gross morphology and cortical thickness. Microscopic examination was possible. This analysis involved comparison of the unknown specimens to reference deer and human thin sections including bone recovered from the woman during autopsy. Examination of the jeep and gas station fragments revealed no plexiform bone, secondary (not primary) osteons, and variability in size and shape of the osteons and Haversian canals. These and other variables identified the bone fragments as human.

Amputation risk factors in concomitant superficial femoral artery and vein injuries.

Only a small subset of patients with combined superficial femoral artery and vein injuries results in amputation. The importance of the venous component as a risk factor for amputation is uncertain. Ligation vs. reconstruction of venous injuries is controversial. For clarification of these issues, we analyzed retrospectively multiple risk factors for amputation in combined superficial femoral artery and vein injuries in a civilian population. There were 25 patients treated in a 20-year period. Sixteen injuries were caused by small caliber missiles, six by shotgun blasts, and three by knife wounds. Three patients (12%) ultimately underwent amputation. The major risk factor for amputation was method of vascular reconstruction. All three amputations underwent ligation of the superficial femoral vein with arterial reconstruction by placement of a reversed interposition saphenous vein graft (p = 0.0009). None of the remaining 22 patients with salvaged limbs underwent reconstruction by this combination of techniques. Consequently, the authors emphasize the importance of venous reconstruction, particularly in combined injuries with major arterial involvement requiring interposed grafts.

Massive thigh injuries with vascular disruption. Role of porcine skin grafting of exposed arterial vein grafts.

Twenty-five patients with extensive soft tissue injury and femoral-popliteal arterial disruption were treated over a four-year period. Injury was most often due to closerange shotgun blasts, and often involved adjacent structures. Of the patients, 72% were admitted in severe shock; all but one were successfully resuscitated. Three patients did well following primary above-knee amputation. The remaining 21 had primary vascular repair, and 14 survived with a viable limb. There were four secondary amputations and four postoperative deaths. Adverse factors affecting survival and limb salvage included inadequate debridement, primary wound closure, failure of the vascular repair, and omission or incomplete fasciotomy. Split-thickness porcine skin grafts were used as a biological dressing to cover an exposed vascular repair in four patients. Limb salvage was achieved in three of these.