“A fear of weapons is a sign of retarded sexual and emotional maturity” Gunshot Wounds: Old and New.

““A fear of weapons is a sign of retarded sexual A fear of weapons is a sign of retarded sexual and emotional maturity”and emotional maturity”

““A fear of weapons is a sign of retarded sexual A fear of weapons is a sign of retarded sexual and emotional maturity”and emotional maturity”

Gunshot Wounds: Old and New

Vocabulary 101Vocabulary 101Vocabulary 101Vocabulary 101

•AutomaticAutomatic

•Semi-AutomaticSemi-Automatic

•Assault RifleAssault Rifle

•CartridgeCartridge

•BulletBullet

•RoundRound

•MagazineMagazine

•ClipClip

USA Gun DeathsUSA Gun DeathsUSA Gun DeathsUSA Gun Deaths

58% suicides (17,000)58% suicides (17,000)

67% homicides (11,000)67% homicides (11,000)

Guns account for 0.7% Guns account for 0.7% Accidental (1/2 hunting Accidental (1/2 hunting 1/2 “mishandling”) (total 1/2 “mishandling”) (total about 800/yr)about 800/yr)

Most weapons in crimes Most weapons in crimes illegally obtainedillegally obtained

58% suicides (17,000)58% suicides (17,000)

67% homicides (11,000)67% homicides (11,000)

Guns account for 0.7% Guns account for 0.7% Accidental (1/2 hunting Accidental (1/2 hunting 1/2 “mishandling”) (total 1/2 “mishandling”) (total about 800/yr)about 800/yr)

Most weapons in crimes Most weapons in crimes illegally obtainedillegally obtained

Year 2000 % of households with gunsYear 2000 % of households with gunsYear 2000 % of households with gunsYear 2000 % of households with guns

United StatesUnited States 48.048.0 IsraelIsrael 92.392.3 SwitzerlandSwitzerland

90.090.0 NorwayNorway 32.032.0 CanadaCanada 29.129.1 FinlandFinland 2323 FranceFrance 22 22

United StatesUnited States 48.048.0 IsraelIsrael 92.392.3 SwitzerlandSwitzerland

90.090.0 NorwayNorway 32.032.0 CanadaCanada 29.129.1 FinlandFinland 2323 FranceFrance 22 22

New ZealandNew Zealand 2222 AustriaAustria 19.419.4 BelgiumBelgium 16.616.6 ItalyItaly 16.016.0 SwedenSweden 15.115.1 Northern INorthern I 8.48.4 ScotlandScotland 4.74.7 England England 4.74.7

New ZealandNew Zealand 2222 AustriaAustria 19.419.4 BelgiumBelgium 16.616.6 ItalyItaly 16.016.0 SwedenSweden 15.115.1 Northern INorthern I 8.48.4 ScotlandScotland 4.74.7 England England 4.74.7

Wounding PotentialWounding PotentialWounding PotentialWounding Potential

RulesRules Energy cannot be Energy cannot be

created or created or destroyeddestroyed

ConsiderConsider Anatomy of impact Anatomy of impact

sitesite Type of Type of

weapon/ammoweapon/ammo PenetrationPenetration

RulesRules Energy cannot be Energy cannot be

created or created or destroyeddestroyed

ConsiderConsider Anatomy of impact Anatomy of impact

sitesite Type of Type of

weapon/ammoweapon/ammo PenetrationPenetration

AmmunitionAmmunitionAmmunitionAmmunition

Cartridge case-Cartridge case- seals seals chamber against rear chamber against rear escape of gasesescape of gases

PrimerPrimer- explodes on - explodes on compressioncompression

PropellantPropellant-burns to produce -burns to produce gases under pressure gases under pressure

MagnumMagnum more pressure more pressure Bullet-Bullet- Part of cartridge Part of cartridge

which exits the muzzlewhich exits the muzzle

Cartridge case-Cartridge case- seals seals chamber against rear chamber against rear escape of gasesescape of gases

PrimerPrimer- explodes on - explodes on compressioncompression

PropellantPropellant-burns to produce -burns to produce gases under pressure gases under pressure

MagnumMagnum more pressure more pressure Bullet-Bullet- Part of cartridge Part of cartridge

which exits the muzzlewhich exits the muzzle

AmmunitionAmmunitionAmmunitionAmmunition

Fully JacketedFully Jacketed Soft PointSoft Point WadcutterWadcutter FrangibleFrangible ExpansionExpansion Weight RetentionWeight Retention PenetrationPenetration

Fully JacketedFully Jacketed Soft PointSoft Point WadcutterWadcutter FrangibleFrangible ExpansionExpansion Weight RetentionWeight Retention PenetrationPenetration

HandgunsHandgunsHandgunsHandguns Most confrontations occur Most confrontations occur

within 7 meterswithin 7 meters 11% of assailants bullets hit 11% of assailants bullets hit

the intended target, while the intended target, while 25% of police bullets hit their 25% of police bullets hit their intended targets.intended targets.

Less range and less velocityLess range and less velocity Shot placement and bullet Shot placement and bullet

characteristics dictate characteristics dictate effectivenesseffectiveness

FBI StudiesFBI Studies 90% of Gun Related 90% of Gun Related

HomicidesHomicides

Most confrontations occur Most confrontations occur within 7 meterswithin 7 meters

11% of assailants bullets hit 11% of assailants bullets hit the intended target, while the intended target, while 25% of police bullets hit their 25% of police bullets hit their intended targets.intended targets.

Less range and less velocityLess range and less velocity Shot placement and bullet Shot placement and bullet

characteristics dictate characteristics dictate effectivenesseffectiveness

FBI StudiesFBI Studies 90% of Gun Related 90% of Gun Related

HomicidesHomicides

Example: H&K MP5 Example: H&K MP5 Pistol Cartridges Pistol Cartridges EFFECTIVE RANGE: 50m EFFECTIVE RANGE: 50m Up to 800 rounds per Up to 800 rounds per

minute minute FEED: 15 or 30 round FEED: 15 or 30 round

magazine magazine

Example: H&K MP5 Example: H&K MP5 Pistol Cartridges Pistol Cartridges EFFECTIVE RANGE: 50m EFFECTIVE RANGE: 50m Up to 800 rounds per Up to 800 rounds per

minute minute FEED: 15 or 30 round FEED: 15 or 30 round

magazine magazine

Submachine gunsSubmachine gunsSubmachine gunsSubmachine guns

RiflesRiflesRiflesRifles

Higher energyHigher energy Easier to be Easier to be

accurateaccurate Long Range - Up to Long Range - Up to

3 miles 3 miles

Higher energyHigher energy Easier to be Easier to be

accurateaccurate Long Range - Up to Long Range - Up to

3 miles 3 miles

ShotgunsShotgunsShotgunsShotguns

Shotguns are capable Shotguns are capable of firing pellets, larger of firing pellets, larger metal balls (buck-metal balls (buck-shot), or slugs.  shot), or slugs. 

These projectiles are These projectiles are loaded into shell with loaded into shell with gunpowder behind gunpowder behind “wadding”“wadding”

00 Buck = 0.31 in00 Buck = 0.31 in

Shotguns are capable Shotguns are capable of firing pellets, larger of firing pellets, larger metal balls (buck-metal balls (buck-shot), or slugs.  shot), or slugs. 

These projectiles are These projectiles are loaded into shell with loaded into shell with gunpowder behind gunpowder behind “wadding”“wadding”

00 Buck = 0.31 in00 Buck = 0.31 in

RangeRangeRangeRange

Direct contact Direct contact Close rangeClose range Energy LostEnergy Lost Entry Entry ExitExit Knockdown - Knockdown - .45 .45

ACP (45 auto) = 1 ACP (45 auto) = 1 lb dropped 11.4 lb dropped 11.4 feet. feet.

Direct contact Direct contact Close rangeClose range Energy LostEnergy Lost Entry Entry ExitExit Knockdown - Knockdown - .45 .45

ACP (45 auto) = 1 ACP (45 auto) = 1 lb dropped 11.4 lb dropped 11.4 feet. feet.

Wound (Terminal) ballistics Wound (Terminal) ballistics Wound (Terminal) ballistics Wound (Terminal) ballistics Weapon, Anatomy and bullet factorsWeapon, Anatomy and bullet factors

Tissue type- Tissue type- Most important FactorMost important Factor Laceration Laceration “drilling effect”-“drilling effect”-Permanent cavityPermanent cavity Tissue Tissue stretchstretch--Temporary cavityTemporary cavity Shock Waves at up to 1500m/s Shock Waves at up to 1500m/s People are not made of Ballistic GelatinPeople are not made of Ballistic Gelatin Fackler - Army research lab - Occult damage-0.5 Fackler - Army research lab - Occult damage-0.5

CM from wound edgeCM from wound edge 125-230fps penetrate skin125-230fps penetrate skin

Weapon, Anatomy and bullet factorsWeapon, Anatomy and bullet factors Tissue type- Tissue type- Most important FactorMost important Factor Laceration Laceration “drilling effect”-“drilling effect”-Permanent cavityPermanent cavity Tissue Tissue stretchstretch--Temporary cavityTemporary cavity Shock Waves at up to 1500m/s Shock Waves at up to 1500m/s People are not made of Ballistic GelatinPeople are not made of Ballistic Gelatin Fackler - Army research lab - Occult damage-0.5 Fackler - Army research lab - Occult damage-0.5

CM from wound edgeCM from wound edge 125-230fps penetrate skin125-230fps penetrate skin

Terminal ballisticsTerminal ballisticsTerminal ballisticsTerminal ballistics Stability –Yaw, precession, nutation (tumble)Stability –Yaw, precession, nutation (tumble) Fragmentation-more likely at higher velocities Fragmentation-more likely at higher velocities Secondary projectilesSecondary projectiles ““Our findings indicate that every bullet's Our findings indicate that every bullet's

path is a unique eventpath is a unique event”” Military Medicine Military Medicine Dec 2001, Korac Dec 2001, Korac

Stability –Yaw, precession, nutation (tumble)Stability –Yaw, precession, nutation (tumble) Fragmentation-more likely at higher velocities Fragmentation-more likely at higher velocities Secondary projectilesSecondary projectiles ““Our findings indicate that every bullet's Our findings indicate that every bullet's

path is a unique eventpath is a unique event”” Military Medicine Military Medicine Dec 2001, Korac Dec 2001, Korac

The Human TargetThe Human TargetThe Human TargetThe Human Target

Anatomic locationAnatomic locationPenetrationPenetrationBullet fragmentationBullet fragmentationRetained Weight of Retained Weight of

ProjectileProjectile““Knockdown”Knockdown”CNS only reliable location CNS only reliable location

for immediate for immediate incapacitationincapacitation

Anatomic locationAnatomic locationPenetrationPenetrationBullet fragmentationBullet fragmentationRetained Weight of Retained Weight of

ProjectileProjectile““Knockdown”Knockdown”CNS only reliable location CNS only reliable location

for immediate for immediate incapacitationincapacitation

GSW headGSW headGSW headGSW head

Groin GSWGroin GSWGroin GSWGroin GSW

Patient ManagementPatient ManagementPatient ManagementPatient ManagementPre-hospital Information (often not reliable)Pre-hospital Information (often not reliable)

ABCDE - examine wounds (esp neck wounds)ABCDE - examine wounds (esp neck wounds)Greater than 80% of those fatally wounded by a bullet die Greater than 80% of those fatally wounded by a bullet die within 30 minutes of injury within 30 minutes of injury Pope A, French G, Longnecker DEPope A, French G, Longnecker DE

SAVE THE STORY FOR THE JURYSAVE THE STORY FOR THE JURY

BleedingBleeding

BleedingBleeding

BleedingBleeding

Recent ResearchRecent Research

Hemostatic DressingHemostatic DressingHemostatic DressingHemostatic Dressing

64 combat uses64 combat uses 25 chest, groin, 25 chest, groin,

buttock, and buttock, and abdomen abdomen

35 extremities35 extremities 4 neck or facial4 neck or facial 97% successful97% successful

64 combat uses64 combat uses 25 chest, groin, 25 chest, groin,

buttock, and buttock, and abdomen abdomen

35 extremities35 extremities 4 neck or facial4 neck or facial 97% successful97% successful

Wedmore, The Journal of Trauma: Injury, Infection, and Critical Care: March 2006 - Volume 60 - Issue 3 - pp 655-658

TourniquetTourniquetTourniquetTourniquetIsraeli Defensive Force ExperienceIsraeli Defensive Force Experience91 cases over 4 year period91 cases over 4 year periodMost common indications for useMost common indications for use

Mass casualtiesMass casualtiesCare under fireCare under fireAmputationsAmputations

NO cases of death by uncontrolled hemorrhage seenNO cases of death by uncontrolled hemorrhage seen How Long can it be left in place?How Long can it be left in place?

Up to 2 hours warm ischemic time standard in orthopedic surgeryUp to 2 hours warm ischemic time standard in orthopedic surgery Every ED an EMS unit should have.Every ED an EMS unit should have.

Ostman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andOstman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andReperfusion in Human Skeletal Muscle. Reperfusion in Human Skeletal Muscle. Clin OrthopClin Orthop: 2004; 418:260-265: 2004; 418:260-265

Klenerman L. Tourniquet Time—How Long? Klenerman L. Tourniquet Time—How Long? HandHand. 1980; 12(3):231-4. 1980; 12(3):231-4

Israeli Defensive Force ExperienceIsraeli Defensive Force Experience91 cases over 4 year period91 cases over 4 year periodMost common indications for useMost common indications for use

Mass casualtiesMass casualtiesCare under fireCare under fireAmputationsAmputations

NO cases of death by uncontrolled hemorrhage seenNO cases of death by uncontrolled hemorrhage seen How Long can it be left in place?How Long can it be left in place?

Up to 2 hours warm ischemic time standard in orthopedic surgeryUp to 2 hours warm ischemic time standard in orthopedic surgery Every ED an EMS unit should have.Every ED an EMS unit should have.

Ostman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andOstman B, Michaelson K, Rahme H et al: Tourniquet-induced Ischemia andReperfusion in Human Skeletal Muscle. Reperfusion in Human Skeletal Muscle. Clin OrthopClin Orthop: 2004; 418:260-265: 2004; 418:260-265

Klenerman L. Tourniquet Time—How Long? Klenerman L. Tourniquet Time—How Long? HandHand. 1980; 12(3):231-4. 1980; 12(3):231-4

Blood ComponentsBlood Components• Component replacement should occur only in the

presence off active bleeding or if interventional procedures are to be undertaken

• Ratio 1RBC:1Platelets:1 FFP• Platelet concentrates (1pack/10kg) are given if platelet

count <50. • FFP (12 ml/kg) is administered if PT or PTT are running

higher than 1.5 times control levels• Cryo 1-1.5 packs/10kgs is given for fibrinogen levels <0.8• Factor VII – No benefit

• J Trauma. 2006 Jul;61(1):181-4 2006 Jul;61(1):181-4• Seaman, D. M. J., Park, G. R.;Trauma.org, resuscitation:

“Transfusion for Massive Blood Loss”.• Massoli, K. L.; Lecture:

“Blood Component Therapy and Massive Transfusion,” Jan., 2003. Stene, J. K., Grande, C. M.:

• Component replacement should occur only in the presence off active bleeding or if interventional procedures are to be undertaken

• Ratio 1RBC:1Platelets:1 FFP• Platelet concentrates (1pack/10kg) are given if platelet

count <50. • FFP (12 ml/kg) is administered if PT or PTT are running

higher than 1.5 times control levels• Cryo 1-1.5 packs/10kgs is given for fibrinogen levels <0.8• Factor VII – No benefit

• J Trauma. 2006 Jul;61(1):181-4 2006 Jul;61(1):181-4• Seaman, D. M. J., Park, G. R.;Trauma.org, resuscitation:

“Transfusion for Massive Blood Loss”.• Massoli, K. L.; Lecture:

“Blood Component Therapy and Massive Transfusion,” Jan., 2003. Stene, J. K., Grande, C. M.:

ManagementManagementManagementManagement

• Wound description - Only what you see

• Small wounds = poss extensive internal damage

• Missiles do not always travel in straight lines

• Consider Intra-abdominal injury

• Vascular injury-hematoma, pulse deficit, bruit, pulsitile or uncontrolled bleeding

• Beware multiple wounds

• Wound description - Only what you see

• Small wounds = poss extensive internal damage

• Missiles do not always travel in straight lines

• Consider Intra-abdominal injury

• Vascular injury-hematoma, pulse deficit, bruit, pulsitile or uncontrolled bleeding

• Beware multiple wounds

Penetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma

History:History: 18001800’’s surgical dogma for nonoperative/supportive s surgical dogma for nonoperative/supportive

care of abdominal GSWcare of abdominal GSW 1881 President James A. Garfield shot in 1881 President James A. Garfield shot in

abdomen. abdomen. ““GarfieldGarfield’’s death watch.s death watch.”” 1890 Sir William McCormick, British chief army 1890 Sir William McCormick, British chief army

surgeon surgeon ““if a man undergoes surgery after being if a man undergoes surgery after being shot, he dies, and lives if left in peace.shot, he dies, and lives if left in peace.””

Continued standard of care through most of WWIContinued standard of care through most of WWI

History:History: 18001800’’s surgical dogma for nonoperative/supportive s surgical dogma for nonoperative/supportive

care of abdominal GSWcare of abdominal GSW 1881 President James A. Garfield shot in 1881 President James A. Garfield shot in

abdomen. abdomen. ““GarfieldGarfield’’s death watch.s death watch.”” 1890 Sir William McCormick, British chief army 1890 Sir William McCormick, British chief army

surgeon surgeon ““if a man undergoes surgery after being if a man undergoes surgery after being shot, he dies, and lives if left in peace.shot, he dies, and lives if left in peace.””

Continued standard of care through most of WWIContinued standard of care through most of WWIBritt, Rushing. “Penetrating Abdominal Trauma.” Current surgical therapy. 9

th Ed. Pp 964-5. 2008

Penetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma History continuedHistory continued

WWI- higher M/M for non op ptWWI- higher M/M for non op pt’’s.s. WWII, Korean war standard of care reversed WWII, Korean war standard of care reversed

to mandatory laparotomy.to mandatory laparotomy. Continued until 1960- Shaftan and Nance Continued until 1960- Shaftan and Nance

endorse endorse ““selective conservatismselective conservatism”” concern concern re:negative lap ratesre:negative lap rates

Tulane 1973Tulane 1973

History continuedHistory continued WWI- higher M/M for non op ptWWI- higher M/M for non op pt’’s.s. WWII, Korean war standard of care reversed WWII, Korean war standard of care reversed

to mandatory laparotomy.to mandatory laparotomy. Continued until 1960- Shaftan and Nance Continued until 1960- Shaftan and Nance

endorse endorse ““selective conservatismselective conservatism”” concern concern re:negative lap ratesre:negative lap rates

Tulane 1973Tulane 1973

Shaftan GW. Indicaton for operation in abdominal trauma. Am J Surg. 99:657, 1960.

Penetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal traumaPenetrating abdominal trauma

History to nowHistory to now Evolution of DPL/CT/ FAST, increases non Evolution of DPL/CT/ FAST, increases non

operative evaluation/treatment in stable operative evaluation/treatment in stable ptpt’’s.s.

Laparoscopic optionsLaparoscopic options

History to nowHistory to now Evolution of DPL/CT/ FAST, increases non Evolution of DPL/CT/ FAST, increases non

operative evaluation/treatment in stable operative evaluation/treatment in stable ptpt’’s.s.

Laparoscopic optionsLaparoscopic options

Britt, Rushing. “Penetrating Abdominal Trauma.”

Current surgical therapy. 9th Ed. Pp 964-5. 2008

Pearls of penetrating abdominal Pearls of penetrating abdominal traumatrauma

Pearls of penetrating abdominal Pearls of penetrating abdominal traumatrauma

Most common injured intraabdominal Most common injured intraabdominal organorgan Small intestineSmall intestine

Most common injured solid organMost common injured solid organ liverliver

Most common injured intraabdominal Most common injured intraabdominal organorgan Small intestineSmall intestine

Most common injured solid organMost common injured solid organ liverliver

Reviewing assessment of Reviewing assessment of abdominal penetrating traumaabdominal penetrating trauma

Reviewing assessment of Reviewing assessment of abdominal penetrating traumaabdominal penetrating trauma

ABCABC’’ss Controlled resuscitationControlled resuscitation Secondary surveySecondary survey Tertiary surveyTertiary survey

Mark all injury sites prior to XrayMark all injury sites prior to Xray Hx of number of shots fired, type of weapon, Hx of number of shots fired, type of weapon,

length of knife, sites of pain, etclength of knife, sites of pain, etc Diagnostic planningDiagnostic planning

ABCABC’’ss Controlled resuscitationControlled resuscitation Secondary surveySecondary survey Tertiary surveyTertiary survey

Mark all injury sites prior to XrayMark all injury sites prior to Xray Hx of number of shots fired, type of weapon, Hx of number of shots fired, type of weapon,

length of knife, sites of pain, etclength of knife, sites of pain, etc Diagnostic planningDiagnostic planning

Indications for emergent Indications for emergent laparotomylaparotomy

Indications for emergent Indications for emergent laparotomylaparotomy

PeritonitisPeritonitis Hemodynamic instabilityHemodynamic instability EviscerationEvisceration Blood from natural orificesBlood from natural orifices impaled objectimpaled object High velocity missile injuryHigh velocity missile injury

PeritonitisPeritonitis Hemodynamic instabilityHemodynamic instability EviscerationEvisceration Blood from natural orificesBlood from natural orifices impaled objectimpaled object High velocity missile injuryHigh velocity missile injury

Operative goals/planOperative goals/planOperative goals/planOperative goals/plan

Stop the bleedingStop the bleeding Control contaminationControl contamination Identify all injuriesIdentify all injuries Definitive repair of injuries vs damage Definitive repair of injuries vs damage

controlcontrol

Stop the bleedingStop the bleeding Control contaminationControl contamination Identify all injuriesIdentify all injuries Definitive repair of injuries vs damage Definitive repair of injuries vs damage

controlcontrol

Hemodynamically stable, No diffuse abdominal tendernessHemodynamically stable, No diffuse abdominal tenderness

CT then OPERATIVE vs. EXPECTANTCT then OPERATIVE vs. EXPECTANT

1/3 have no significant injuries 1/3 have no significant injuries (Demetriades, Cornwell, et al, Arch Surg, 1997)(Demetriades, Cornwell, et al, Arch Surg, 1997)

2/3 to back have no sign. injuries 2/3 to back have no sign. injuries (Velmahos, Demetriades, et al, Am J Surg, 1997)(Velmahos, Demetriades, et al, Am J Surg, 1997)

CT can demonstrate trajectory, relation to vital structures,CT can demonstrate trajectory, relation to vital structures,

Site and size of solid organ injury, presence of pseudoaneurysmSite and size of solid organ injury, presence of pseudoaneurysm

<5% of pts managed nonoperatively will need subsequent laparotomy<5% of pts managed nonoperatively will need subsequent laparotomy

<0.5% will have any associated complications from the delay<0.5% will have any associated complications from the delay

Selective Operative Selective Operative ManagementManagement

Selective Operative Selective Operative ManagementManagement

111 patients with GSW to abdomen111 patients with GSW to abdomen

Laparotomy decision based on physical examination aloneLaparotomy decision based on physical examination alone

80% immediate laparotomy80% immediate laparotomy

8% negative lap8% negative lap

20% conservative management20% conservative management

None required delayed laparotomyNone required delayed laparotomy

Muckart DJ, Abdool-Carrim AT, King B. Selective conservative management of abdominal gunshot wounds: a

prospective study. Br J Surg 1990, 77(6):652-5.

146 pts with GSW to abdomen146 pts with GSW to abdomen

105 (72%) acute abdomen, immediate exploration105 (72%) acute abdomen, immediate exploration

41 (28%) equivocal or minimal exam, observed41 (28%) equivocal or minimal exam, observed

7 (17% of observed group) required laparotomy, no added 7 (17% of observed group) required laparotomy, no added morbiditymorbidity

Demetriades D, Charalambides D, et al. Gunshot wound of the abdomen: role of selective conservative management.

Br J Surg 1991, 78(2):220-2.

Velmahos, Demetriades, et al. Selective Nonoperative Management in 1,856 Patients with Abdominal Gunshot

Wounds. Ann Surg. 2001; 234(3):395-403.

8 year period at one trauma center8 year period at one trauma center

1856 patients seen with abdominal GSW1856 patients seen with abdominal GSW

1405 anterior. 451 posterior.1405 anterior. 451 posterior.

792 managed nonoperatively792 managed nonoperatively

(34% anterior, 68% posterior).(34% anterior, 68% posterior).

Exclusion criteria:Exclusion criteria:

peritonitis, hemodynamic instability, unreliableperitonitis, hemodynamic instability, unreliable exam

Velmahos, Demetriades, et al. Selective Nonoperative Management in 1,856 Patients with Abdominal Gunshot

Wounds. Ann Surg. 2001; 234(3):395-403.

4% progressed to delayed laparotomy4% progressed to delayed laparotomy

only 61% needed even this laparotomyonly 61% needed even this laparotomy

0.3% had complications related to delay of operation0.3% had complications related to delay of operation

(abscess, pneumonia, ileus)(abscess, pneumonia, ileus)

Cost analysis:Cost analysis:

routine laparotomy: 47% would have been unnecessaryroutine laparotomy: 47% would have been unnecessary

3560 hospital days saved3560 hospital days saved

$10 million saved$10 million saved

Santucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaOutcome Status Stab (N=87) GSW (N=52) P-value

Transfusion Yes 14 (16%) 40 (77%) <.0001

No 73 (84%) 12 (23%)

Nephrectomy Yes 0 (0%) 16 (31%) <.0001

No 87 (100%) 36 (69%)

Delayed Complication

Yes 9 (10%) 4 (8%) 0.767

No 78 (90%) 48 (92%)

Santucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal TraumaSantucci 2007, Renal Trauma

Expectant management is a reasonable Expectant management is a reasonable option for the treatment of renal stab woundsoption for the treatment of renal stab wounds

Approximately 50% of patients with LVGSW Approximately 50% of patients with LVGSW will require GU-specific surgical interventionwill require GU-specific surgical intervention

HVGSW mandated more aggressive HVGSW mandated more aggressive treatment treatment

A renal salvage rate of 88.5% (123/139) for A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with penetrating trauma was achieved with selected exploration and an organ preserving selected exploration and an organ preserving strategy for grades II-IV renal injury.strategy for grades II-IV renal injury.

Expectant management is a reasonable Expectant management is a reasonable option for the treatment of renal stab woundsoption for the treatment of renal stab wounds

Approximately 50% of patients with LVGSW Approximately 50% of patients with LVGSW will require GU-specific surgical interventionwill require GU-specific surgical intervention

HVGSW mandated more aggressive HVGSW mandated more aggressive treatment treatment

A renal salvage rate of 88.5% (123/139) for A renal salvage rate of 88.5% (123/139) for penetrating trauma was achieved with penetrating trauma was achieved with selected exploration and an organ preserving selected exploration and an organ preserving strategy for grades II-IV renal injury.strategy for grades II-IV renal injury.

Benefit: Avoidance of Unnecessary LaparotomiesBenefit: Avoidance of Unnecessary Laparotomies

Analysis of 16 major studies, 8111 SW/GSW patientsAnalysis of 16 major studies, 8111 SW/GSW patients

1667 (21%) unnecessary laparotomies with 11% morbidity1667 (21%) unnecessary laparotomies with 11% morbidity

(pneumonia, ileus, wound ifxn, SBO, incisional hernia)(pneumonia, ileus, wound ifxn, SBO, incisional hernia)

Higher length of stay (5-10d vs 1-2d)Higher length of stay (5-10d vs 1-2d)

Much higher cost (up to $10,000 extra hosptial charges per patient)Much higher cost (up to $10,000 extra hosptial charges per patient)

Sequelae: Consequences of Missed InjuriesSequelae: Consequences of Missed Injuries

Analysis of 5 prospective studies, 728 patientsAnalysis of 5 prospective studies, 728 patients

25 (3.4%) with delayed diagnosis of injuries25 (3.4%) with delayed diagnosis of injuries

7 (28%) complications, no deaths7 (28%) complications, no deaths

(wound ifxn, abscess, ARDS, pancreatic fistula)(wound ifxn, abscess, ARDS, pancreatic fistula)

Selective Operative Selective Operative ManagementManagement

Selective Operative Selective Operative ManagementManagement

UK algorithm: Penetrating Trauma

EAST Guideline 2010EAST Guideline 2010EAST Guideline 2010EAST Guideline 2010

Peritonitis, Unstable – Ex Lap (I)Peritonitis, Unstable – Ex Lap (I) MS changes/CNS injury – Ex Lap or MS changes/CNS injury – Ex Lap or

Immediate Imaging (I)Immediate Imaging (I) Stable vitals, tangential GSW – no Ex Lap, Stable vitals, tangential GSW – no Ex Lap,

Imaging (II)Imaging (II) Serial exams are reliable (II)Serial exams are reliable (II) CT for non op patients (II)CT for non op patients (II) Consider laparoscopy (II)Consider laparoscopy (II)

Peritonitis, Unstable – Ex Lap (I)Peritonitis, Unstable – Ex Lap (I) MS changes/CNS injury – Ex Lap or MS changes/CNS injury – Ex Lap or

Immediate Imaging (I)Immediate Imaging (I) Stable vitals, tangential GSW – no Ex Lap, Stable vitals, tangential GSW – no Ex Lap,

Imaging (II)Imaging (II) Serial exams are reliable (II)Serial exams are reliable (II) CT for non op patients (II)CT for non op patients (II) Consider laparoscopy (II)Consider laparoscopy (II)

SummarySummarySummarySummary

• Treat patient and wound NOT the weapon

• Reassess • Describe wounds

simply• Think - bullet path

• Treat patient and wound NOT the weapon

• Reassess • Describe wounds

simply• Think - bullet path

QUESTIONSQUESTIONSQUESTIONSQUESTIONS

Weapon Safety 101Weapon Safety 101Weapon Safety 101Weapon Safety 101

For All You Gun NutsFor All You Gun NutsFor All You Gun NutsFor All You Gun Nuts All weapons are loadedAll weapons are loaded Never point the muzzle at Never point the muzzle at

anything you do not want anything you do not want to destroyto destroy

Finger OFF the trigger till Finger OFF the trigger till ready to fireready to fire

All weapons are loadedAll weapons are loaded Never point the muzzle at Never point the muzzle at

anything you do not want anything you do not want to destroyto destroy

Finger OFF the trigger till Finger OFF the trigger till ready to fireready to fire

MYTHSMYTHSMYTHSMYTHS

Kinetic energy explains Kinetic energy explains tissue injury tissue injury

Entrance and exit can Entrance and exit can be easily determinedbe easily determined

High velocity wounds all High velocity wounds all need extensive need extensive debridementdebridement

Knockdown PowerKnockdown Power

Kinetic energy explains Kinetic energy explains tissue injury tissue injury

Entrance and exit can Entrance and exit can be easily determinedbe easily determined

High velocity wounds all High velocity wounds all need extensive need extensive debridementdebridement

Knockdown PowerKnockdown Power