Penetratingtrauma

Penetrating trauma in Netherlands Antilles?No difference!

Penetrating trauma in Netherlands Antilles?No difference!

Jeannouel van Leeuwen MDTrauma in the Caribbean II

November 6-8, 2009

Jeannouel van Leeuwen MDTrauma in the Caribbean II

November 6-8, 2009

Woundman, from Hans von Gersdorff, Feldtbuch der Wundartzney, 1517.

Epidemiology of Epidemiology of Penetrating TraumaPenetrating TraumaEpidemiology of Epidemiology of Penetrating TraumaPenetrating Trauma

• In 2002 firearms In 2002 firearms caused 30,242 caused 30,242 deaths for a rate of deaths for a rate of 10.5 per 100,000 10.5 per 100,000 residentsresidents

• Rate of penetrating Rate of penetrating trauma is 20% in trauma is 20% in the USthe US

Surgery is the most dangerous activity in legal society

4

Physics of Penetrating TraumaPhysics of Penetrating Trauma

• Recall Kinetic Energy Equation

– Greater the mass the greater the energy• Double mass = double KE

– Greater the speed the greater the energy• Double speed = 4x increase KE

2

)()( 2speedVelocityweightMassKE

Surgery is a controlled trauma under anaesthesia

Physics of Penetrating TraumaPhysics of Penetrating Trauma• Remainder of energy propels bullet forward

at a high rate of speed.

• Trajectory is curved due to gravity

• As bullet strikes object, it slows and energy is transferred to object.

– Law of Conservation of Energy

A Lesson From EinsteinA Lesson From Einstein

• Energy cannot be created or destroyed• Force has to go somewhere• Energy is transmitted

through human tissue

• Newton’s Law of Physics Force= Change in Velocity x Mass

Everything should be made as simple as possible , but not simpler

Mechanisms of Injury in Penetrating Mechanisms of Injury in Penetrating TraumaTraumaMechanisms of Injury in Penetrating Mechanisms of Injury in Penetrating TraumaTrauma

• Low velocity injuries Low velocity injuries – Knife woundsKnife wounds– Disrupt only the structures penetratedDisrupt only the structures penetrated

• Medium velocity injuriesMedium velocity injuries– Handguns and pellet gunsHandguns and pellet guns

• High Velocity InjuriesHigh Velocity Injuries– Military weapons and riflesMilitary weapons and rifles

• Shotgun injuries are usually considered Shotgun injuries are usually considered medium velocity but tend to cause a large medium velocity but tend to cause a large amount of injury due to transmitted kinetic amount of injury due to transmitted kinetic energyenergy

Type of weapon involved.

Path of weapon.

Depth of penetration.

Number of wounds.

Underlying anatomy.

Type of weapon involved.

Path of weapon.

Depth of penetration.

Number of wounds.

Underlying anatomy.

Assessment of Low-Energy InjuriesAssessment of Low-Energy Injuries

It is easier to stay out of trouble than to get out of it

High-Energy Penetrating InjuriesHigh-Energy Penetrating Injuries

How do these weapons differ from handguns How do these weapons differ from handguns and shotguns?and shotguns?

How do the wounds differ internally and externally?

How do the wounds differ internally and externally?

Medium-Energy Penetrating InjuriesMedium-Energy Penetrating Injuries

Low-Energy Penetrating WoundsLow-Energy Penetrating Wounds

How does the length

of the weapon relate

to the cone of

damage?

How does the length

of the weapon relate

to the cone of

damage?

Low-Energy InjuriesLow-Energy Injuries

Low velocity.

Usually hand-driven weapons.

Less secondary trauma.

Multiple wounds from a single weapon.

Low velocity.

Usually hand-driven weapons.

Less secondary trauma.

Multiple wounds from a single weapon.

Damage PathwayDamage Pathway

• Direct Injury– Damage done as the projectile strikes tissue

• Pressure Shock Wave– Human tissue is semi-fluid– Solid and dense organs are damaged greatly

• Temporary Cavity– Due to cavitation

• Permanent Cavity– Due to seriously damaged tissue

• Zone of Injury– Area that extends beyond the area of permanent injury

Damage PathwayDamage Pathway

• Projectile Injury Process– Tip impacts tissue– Tissue pushed forward and to the side– Tissue collides with adjacent tissue

• Shock wave of pressure forward and lateral– Moves perpendicular to bullet path

– Rapid compression, crushes and tears tissue– Cavity forms behind bullet pulling in debris

with suction.

ProjectilesProjectiles

• Different types of projectiles will cause different types of wounds

Every bullet tells a story

Good judgement comes from experience. Experience comes from poor judgement.

Wound CharacteristicsWound Characteristics

• Entrance Wounds– Size of bullet profile for non-deforming bullets– Deforming projectiles may cause large

wounds– Close Range

• Powder Burns (Tattooing of powder)• 1-2 mm circle of discoloration• Localized subcutaneous emphysema

• Exit Wounds– Appears to be “Blown” outward

• Pressure wave

General Body RegionsGeneral Body Regions

• Neck– Damages Trachea and Blood Vessels– Neurological problems– Sucking neck wound

• Head– Cavitational energy trapped inside skull– Serious bleeding and lethal

Specific Tissue & Organ InjuriesSpecific Tissue & Organ Injuries• Lungs

– Air in lung absorbs energy– Parenchyma is compressed and rebounds– Pneumothorax or hemothorax can result

• Bone– Resists displacement until it shatters– Alters projectile path

Now go and treat soft tissue injuries….Now go and treat soft tissue injuries….

Reason #1 why you’re supposed to wear a helmet!

Head TraumaHead Trauma

Boy, it almost feels likeI’ve been shot with an

arrow.

Head TraumaHead Trauma

Yup, that definitelyfeels like an arrow.

Transmediastinal Chest WoundsTransmediastinal Chest WoundsTransmediastinal Chest WoundsTransmediastinal Chest Wounds

• The area bordered by the The area bordered by the sternum, spine, and lungs sternum, spine, and lungs which includes the which includes the trachea, aorta, vena trachea, aorta, vena cava, heart, and cava, heart, and esophagusesophagus

• Two thirds of these Two thirds of these injuries are lethalinjuries are lethal– Pericardial tamponadePericardial tamponade– Cardiac or great vessel Cardiac or great vessel

injuryinjury– Esophageal or Esophageal or

Transbronchial InjuryTransbronchial Injury

Penetrating Chest TraumaPenetrating Chest TraumaPenetrating Chest TraumaPenetrating Chest Trauma

• Location, location!!!Location, location!!!– TransmediastinalTransmediastinal– CentralCentral– ThoracoabdominalThoracoabdominal– PeripheralPeripheral

General Body RegionsGeneral Body Regions

• Extremities– Injury limited to resiliency of tissue– 60-80% of injuries with <10% mortality

• Abdomen (Includes Pelvis)– Highly susceptible to injury and hemorrhage– Bowel perforation: 12-24 hrs peritoneal

irritation• Thorax

– Rib impact results in explosive energy– Heart & great vessels have extensive damage

due to lack of fluid compression– Any large chest wound compromises

breathing

Evaluation and ManagementEvaluation and ManagementEvaluation and ManagementEvaluation and Management

• Thoracotomy or clam-shell thoracotomy Thoracotomy or clam-shell thoracotomy necessary if loss of vital signsnecessary if loss of vital signs

• EchocardiographyEchocardiography• Aortography or CT angiogramAortography or CT angiogram• Bronchoscopy to eval tracheobronchial Bronchoscopy to eval tracheobronchial

injuriesinjuries

Penetrating Chest TraumaPenetrating Chest TraumaPenetrating Chest TraumaPenetrating Chest Trauma

• Accounts for 20-Accounts for 20-25% of trauma 25% of trauma related deathsrelated deaths

• 16,000 US deaths a 16,000 US deaths a year due to chest year due to chest traumatrauma

Special Concerns with Penetrating TraumaSpecial Concerns with Penetrating Trauma

• Penetrating Wound Care– Facial Wounds

• Difficult intubations– Depress chest– Pass ET through bubbling tissue– Consider Cricothyroidotomy

• Chest Wounds– Pneumothorax

• 2/3” the diameter of the trachea or larger to entrain air• 3-sided occlusive dressing• Needle Decompress

– Pericardial Tamponade

Pericardial Pericardial EffusionEffusion

Peripheral Thoracic InjuriesPeripheral Thoracic InjuriesPeripheral Thoracic InjuriesPeripheral Thoracic Injuries

• Normal initial chest x rayNormal initial chest x ray• 6 hour chest xray6 hour chest xray• If negative, patient can be dischargedIf negative, patient can be discharged• These patients need angiography if:These patients need angiography if:

– Supraclavicular or axillary hematomaSupraclavicular or axillary hematoma– Ongoing bleedingOngoing bleeding– Pulse deficit in extremitiesPulse deficit in extremities– Apical hematoma on CXRApical hematoma on CXR

Anterior Central WoundsAnterior Central WoundsAnterior Central WoundsAnterior Central Wounds

• Echo to eval for hemopericardiumEcho to eval for hemopericardium– Consider repeating in 6 hours for best Consider repeating in 6 hours for best

sensitivitysensitivity– Or consider CT chestOr consider CT chest

……because we care about the because we care about the diaphragm!diaphragm!……because we care about the because we care about the diaphragm!diaphragm!• Diaphragm can rise as high as the 4Diaphragm can rise as high as the 4 thth

thoracic vertebraethoracic vertebrae• Diaphragmatic injury occurs in Diaphragmatic injury occurs in

– 45% of thoracoabdominal GSWs45% of thoracoabdominal GSWs– 15% of thoracoabdominal stab wounds15% of thoracoabdominal stab wounds

• Injuries are more common on the leftInjuries are more common on the left

FAST ScanFAST ScanFAST ScanFAST Scan

• Good for identification Good for identification of pericardial fluidof pericardial fluid

• Positive fast scan Positive fast scan does not tell you does not tell you which organ is injuredwhich organ is injured

• Negative fast scan Negative fast scan does not exclude does not exclude injuryinjury

Local Wound ExplorationLocal Wound ExplorationLocal Wound ExplorationLocal Wound Exploration

• Extend wound and follow Extend wound and follow the tractthe tract

• Penetration of the Penetration of the anterior abdominal fascia anterior abdominal fascia is considered positive and is considered positive and patient gets laparotomypatient gets laparotomy

• 25% of anterior 25% of anterior abdominal stab wounds abdominal stab wounds do not penetratedo not penetrate

• Only 50% that do Only 50% that do penetrate actually require penetrate actually require surgical interventionsurgical intervention

Diagnostic Options in Diagnostic Options in Thoracoabdominal InjuriesThoracoabdominal InjuriesDiagnostic Options in Diagnostic Options in Thoracoabdominal InjuriesThoracoabdominal Injuries• DPL DPL • CT – low sensitivity in diaphragm injuries, but CT – low sensitivity in diaphragm injuries, but

defines solid organ injuriesdefines solid organ injuries• UltrasoundUltrasound• LaparoscopyLaparoscopy• ThoracoscopyThoracoscopy

Serial Physical ExamsSerial Physical ExamsSerial Physical ExamsSerial Physical Exams

• 24 hour obs24 hour obs• Hourly physical exams Hourly physical exams

by same personby same person• Checking for Checking for

hemodynamic instability hemodynamic instability or development of or development of peritonitisperitonitis

• Sensitive for injury but Sensitive for injury but has disadvantages of has disadvantages of time, moneytime, money

Flank or Back Stab WoundsFlank or Back Stab WoundsFlank or Back Stab WoundsFlank or Back Stab Wounds

• INJURIES TO RETROPERITONEAL ORGANS SUCH AS THE COLON, KIDNEY AND LUMBAR VESSELS - OR MORE RARELY THE PANCREAS, AORTA AND INFERIOR VENA CAVA

• COLON IS THE INJURY MOST OFTEN MISSED

• CT SCAN. WHERE THE WOUND TRACK EXTENDS UP TO THE COLON, OR THERE IS EVIDENCE OF ABNORMAL BOWEL WALL THICKENING, LAPAROTOMY IS INDICATED

Diagnostic OptionsDiagnostic OptionsDiagnostic OptionsDiagnostic Options

• Serial Physical Examination (PE) Serial Physical Examination (PE) • Local Wound Exploration (LWE) Local Wound Exploration (LWE) • Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) • Ultrasound (FAST) Ultrasound (FAST) • CT Scan CT Scan • Laparoscopy Laparoscopy • LaparotomyLaparotomy

If you see two surgeons laughing, someone is in trouble

Stable PatientsStable PatientsStable PatientsStable Patients

• Evaluate for injury – “A tube or finger in every Evaluate for injury – “A tube or finger in every orifice!”orifice!”– Chest XrayChest Xray– NG TubeNG Tube– Urinary CatheterUrinary Catheter– Rectal Exam/Vaginal ExamRectal Exam/Vaginal Exam

• If signs of peritonitis – then to OR!If signs of peritonitis – then to OR!

Unstable PatientsUnstable PatientsUnstable PatientsUnstable Patients

• Need to go to ORNeed to go to OR• Decide which cavity to open firstDecide which cavity to open first

– Obvious penetrating injury to abdomen Obvious penetrating injury to abdomen requires laparotomyrequires laparotomy

– Questions may arise if multiple area Questions may arise if multiple area penetrating trauma, massive hemothorax, penetrating trauma, massive hemothorax, evidence of tamponade, “grey zone areas” evidence of tamponade, “grey zone areas” such as thoracoabdominal junction, buttock such as thoracoabdominal junction, buttock woundwound

– Sometimes need diagnostic testingSometimes need diagnostic testing• Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• FAST ScanFAST Scan• Beware of CT in unstable patientsBeware of CT in unstable patients

Penetrating Abdominal TraumaPenetrating Abdominal TraumaPenetrating Abdominal TraumaPenetrating Abdominal Trauma

• abdomen extends abdomen extends from the nipples to from the nipples to the groin crease the groin crease anteriorly, and the tips anteriorly, and the tips of the scapulae to the of the scapulae to the gluteal skin crease gluteal skin crease inferiorly. inferiorly.

Abdominal Injuries: EviscerationAbdominal Injuries: Evisceration

• Definition: • Organs protruding through

wound

• Treatment:• DO NOT TOUCH OR

REPLACE the organ• Cover with a sterile dressing

moistened with sterile water• Cover with a dry sterile

dressing and tape in place• Cover with plastic wrap• Tape completely around the

border of the dressing • Flex the pts hips and knees, if

uninjured

It is better to see the outside of the artery before you see the inside

Pulseless Penetrating Abdominal Pulseless Penetrating Abdominal TraumaTraumaPulseless Penetrating Abdominal Pulseless Penetrating Abdominal TraumaTrauma• Major vascular injury has occurredMajor vascular injury has occurred• Patient has loss of vital signsPatient has loss of vital signs• Need immediate laparotomy (i.e. within 5 Need immediate laparotomy (i.e. within 5

minutes of arrival) or ED thoracotomy with minutes of arrival) or ED thoracotomy with aortic cross clampingaortic cross clamping

• Eviscerate and go for the bleederEviscerate and go for the bleeder

The lowest mortality and fewest complications result from the removal of normal tissue

Pulseless Penetrating Abdominal Pulseless Penetrating Abdominal TraumaTraumaPulseless Penetrating Abdominal Pulseless Penetrating Abdominal TraumaTrauma

Surgical complications are more likely on public holidays

Penetrating Abdominal TraumaPenetrating Abdominal TraumaPenetrating Abdominal TraumaPenetrating Abdominal Trauma

Frequent dilemma:take your wife for dinner or the patient back to the OR?

Buttock or Perineum InjuryButtock or Perineum InjuryButtock or Perineum InjuryButtock or Perineum Injury

• Missed rectal injury Missed rectal injury is dangerousis dangerous

• Requires Requires proctoscopy and proctoscopy and sigmoidoscopysigmoidoscopy

Impalement TreatmentImpalement Treatment

• Stabilize the victim• Stabilize the impaled object• ABC’s• Advanced life support (IV, decompression,

etc.)• DO NOT REMOVE THE

OBJECT

Take Home Message – Don’t get shot Take Home Message – Don’t get shot or stabbed!!!or stabbed!!!Take Home Message – Don’t get shot Take Home Message – Don’t get shot or stabbed!!!or stabbed!!!