Transcervical gunshot injuries

Lesiones mortales por armas traumáticas: reporte de caso

Introducción. Las armas de energía cinética son diseñadas para generar lesiones dolorosas y superficiales. Sin embargo, las lesiones asociadas causan confusión al ser abordadas como heridas por proyectil de arma de fuego, convirtiendo el enfoque y el manejo correcto en un desafío. El caso presentado describe un paciente herido en el cuello por arma traumática con el objetivo de analizar factores que permitan identificar este tipo de heridas y sus implicaciones en el manejo. Caso clínico. Paciente masculino de 31 años que ingresó con intubación orotraqueal, remitido de una institución de nivel 2, con herida por aparente proyectil de arma de fuego con trayectoria transcervical. Se encontró hemodinámicamente estable, pero con dificultad para la valoración clínica, por lo que se realizaron exámenes complementarios que descartaron lesión aerodigestiva. La tomografía de cuello reportó proyectil alojado en musculatura paravertebral izquierda, descartando trayectoria transcervical. Discusión. El comportamiento de las lesiones asociadas a los proyectiles de armas depende de varios factores, como el tipo de material del proyectil, su velocidad y las propiedades del tejido impactado. Se presentó un caso en que inicialmente se sospechaba una lesión transcervical, pero con la evaluación se identificó el proyectil cinético en la musculatura paravertebral. Conclusión. En el abordaje de un paciente con sospecha de herida por proyectil de arma de fuego se debe considerar ante todo la respuesta clínica y la correlación del supuesto vector del proyectil con las lesiones sospechadas. La evaluación imagenológica permite identificar oportunamente los proyectiles y evitar procedimientos o terapias innecesarias que forman parte del manejo convencional del paciente con trauma penetrante.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

A national survey on esophageal perforation: study of cases at accredited institutions by the Japanese Esophagus Society

OBJECTIVE

To get a clear view of the current state of treatment for esophageal perforation in Japan. Esophagus perforations are the most serious gastrointestinal tract perforations and are associated with high morbidity and mortality. The optimal treatment choice remains unknown.

METHODS

We conducted a retrospective clinical review of 182 esophageal perforation cases at 108 hospitals accredited by the Japanese Esophageal Society between January 2010 and December 2015.

RESULTS

We found that 20.9% of patients were incorrectly diagnosed initially. We observed mediastinum emphysema in 83.5% of patients, and serious abscess formations of the mediastinum and intrathoracic cavity in 38.6% and 29.6%, respectively. The lower esophagus was the most commonly perforated site (77.7%). Management of esophageal perforations included nonoperative treatment in 20 patients (11%) and operative treatment in 162 patients (89%). The overall mortality rate was 6.9%. The survivors had significantly shorter times from symptom appearance to visit (p = 0.0016), and from time to visit to diagnosis confirmation (p = 0.0011). Moreover, patients older than 65 years, white blood cells less than 3000/mm³, C-reactive protein > 10 mg/L, or abscesses in the thoracic cavity showed significantly higher mortality than others.

CONCLUSION

Shortening the time from onset to the start of treatment contributes to reduce mortality in patients with esophageal perforation. Moreover, strict medical treatment is necessary to lower the mortality rate of elderly patients with strong inflammation and abscesses in the thoracic cavity.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

The early hospital management of gunshot wounds. Part 1: head, neck and thorax

The management of gunshot wounds is an increasing problem for UK emergency doctors, but not to an extent where it has become routine or allowed individuals to gain significant experience in their treatment. This article reviews the pathophysiology of gunshot injury in general before examining the evidence available concerning the management of gunshot wounds to the head neck and thorax.

A comparative audit of gunshot wounds and stab wounds to the neck in a South African metropolitan trauma service

Introduction The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI). Methods A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications. Results There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a 'significant cervical injury' was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients. Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%). Conclusions Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be managed conservatively with a good outcome. Imaging should be performed for all GSWs to the neck.

Using vascular quality initiative as a platform for organizing multicenter, prospective, randomized clinical trials: OVERPAR trial

BACKGROUND

We describe the organization of a prospective, randomized, multicenter trial comparing the effectiveness of open popliteal artery aneurysm repair (OPAR) and endovascular popliteal artery aneurysm repair (EPAR) of asymptomatic popliteal artery aneurysms (PAAs) as an example for how to use the Vascular Quality Initiative (VQI) framework. Given that many centers participate in the VQI, this model can be used to perform multicenters' prospective trials on very modest budget.

METHODS

VQI prospectively collects data on many vascular procedures. These data include many important perioperative, intraoperative, and postoperative details regarding both patients and their procedures. We describe a study where minimal changes to the collected data by participating centers can provide level-1 evidence regarding a significant clinical question. Data will be collected using modified VQI forms within the existing VQI data reporting structure. We plan to enroll 148 patients with asymptomatic PAAs into the open and endovascular surgery cohorts. Patients from participating VQI centers will be randomized 1:1 to either OPAR or EPAR and will be followed for an average of 2.5 years. Our primary hypothesis is that major adverse limb event-free survival is lower in the EPAR cohort and that EPAR is associated with more secondary interventions, improved quality of life, and decreased length of stay. The budget for this trial is fixed at $10,000/year for the course of the study, and the trial is judged to be feasible because of the functionality of the VQI platform.

CONCLUSIONS

Using the existing VQI infrastructure, Open versus Endovascular Repair of Popliteal Artery Aneurysm will provide level 1 data for PAA treatment on a modest budget. The proposed trial has an adequately powered comparative design that will use objective performance goals to describe limb-related morbidity and procedural reintervention rates.

Pathogenesis and outcomes of traumatic injuries of the esophagus

Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross-sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98-3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65-5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50-4.71]) and male gender (OR = 1.52 [1.46-1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07-1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39-1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (∼46%) and mortality (∼20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.

The role of aerodigestive tract endoscopy in penetrating neck trauma

OBJECTIVE/HYPOTHESIS

To determine the role of aerodigestive tract endoscopy in the management of penetrating neck trauma.

STUDY DESIGN

Retrospective case series.

METHODS

A search of the hospital's trauma database was performed for patients who presented with penetrating neck trauma between July 1989 and June 2008. The mechanism and site of injury, airway status and manipulation, physical findings, diagnostic and therapeutic steps taken, and outcomes were all recorded.

RESULTS

One hundred sixty-three patients were identified. There were 144 males and 19 females. The mean age was 28 years (range, 13 to 65 years). There were 105 gunshot wounds, 9 shotgun injuries, and 48 stab wounds. Seventy-three patients (45%) underwent emergent neck exploration, of which 15 had upper aerodigestive tract injuries; intraoperative endoscopy was performed on 13 and was used to guide the repair. Ninety patients (55%) did not meet the criteria for emergent neck exploration. Endoscopy in this group was performed in symptomatic patients, which revealed two cases of unilateral true vocal fold motion impairment, one mucosal laceration of the right mainstem bronchus, one questionable area of injury at the apical segment of the right upper lobe bronchus, and one mucosal laceration of the proximal esophagus.

CONCLUSIONS

Aerodigestive tract endoscopy is critical in assessing and guiding surgical repair of injuries noted on surgical exploration. In stable patients with a low clinical suspicion of aerodigestive tract injury, it was of low yield. We propose a new algorithm for assessing aerodigestive tract injuries that includes multidetector computed tomography, in which only symptomatic patients who fail to meet the criteria for emergent neck exploration undergo endoscopy.

LEVEL OF EVIDENCE

4.

Vascular injuries: trends in management

ABSTRACT

Vascular injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent loss of life or limb. Sometimes serious vascular injury presents with only subtle or occult signs or symptoms. The patient may present weeks or months after initial injury with symptoms of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula etc. Although the majority of vascular injuries are caused by penetrating trauma from gunshot wounds, stabbing or blast injury, the possibility of vascular injury needs to be considered in patients presenting with displaced long bone fractures, crush injury, prolonged immobilization in a fixed position by tight casts or bandages and various invasive procedures. iatrogenic vascular injuries constitute about 10% of cases in most series; however the incidence is an increasing trend because more endovascular procedures such as angioplasty and cardiac catheterization are being performed routinely. Civilian trauma is more frequently seen in young males. However, it can occur at any age due to road accidents, firearms, bomb blasts and diagnostic procedures. Most of the time, civilian trauma causes less tissue damage. There is an epidemic of vascular injuries in Kashmir valley because of problems in law and order in the past two decades. This review deals with the topic in detail.

Profile of missile-induced cardiovascular injuries in Kashmir, India

BACKGROUND

Missile cardiovascular injuries have taken an epidemic proportion in Kashmir valley since the eruption of militancy in 1990. Present study was undertaken to analyse the pattern, presentation and management of missile cardiovascular injuries.

PATIENTS AND METHODS

Three hundred and eighty-six patients with missile cardiovascular injuries since Jan 1996 to Oct 2008 were studied retrospectively. All patients of cardiovascular injuries due to causes other than missiles were excluded from the study.

RESULTS

All patients of missile cardiac injuries were treated by primary cardiorrhaphy. Right ventricle was the most commonly affected chamber. Left anterior thoracotomy was most common approach used. Most of the patients of missile vascular group were treated by reverse saphenous vein graft or end-to-end anastomosis. Most common complication was wound infection (20.83%) followed by graft occlusion (1.94%) in missile vascular group. Amputation rate was 4.66%. Amputation rate was higher in patients with delay of >6 hours and associated fractures.

CONCLUSION

Missile cardiac injuries should be operated early without wasting time for investigations. Clinical status at arrival, time interval till management, nature of injury and associated injuries, tell upon the mortality. Missile vascular injury needs prompt resuscitation and revascularization at the earliest. Time interval till revascularization and associated fractures has a bearing on mortality and morbidity.

Vascular injuries after bear attacks: Incidence, surgical challenges and outcome

BACKGROUND

Bear mauling is rarely reported in medical literature due to its rare occurrence. Present study was undertaken to describe the pattern and management of bear maul vascular injuries in Kashmir.

PATIENTS AND METHODS

Study of patients with bear maul vascular injury from 1(st) Jan 2004 to 31(st) Dec. 2008. Fifteen patients with bear maul vascular injury were studied. All patients of bear maul without vascular injury were excluded from the study.

RESULTS

Most of the patients were treated by reverse saphenous vein graft or end to end anastomosis. Most common complication was wound infection (20%) followed by graft occlusion (13.33%). There was no operative death.

CONCLUSION

Bear attacks are very common in Kashmir. Vascular injury due to bear maul needs prompt resuscitation and revascularization. Results are very good provided timely intervention for revascularization is done.

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.

Penetrating air gun wound in the neck

BACKGROUND

Injuries from air weapons can be serious and potentially fatal. It has been estimated that up to four million such weapons exist in UK households.

CASE REPORT

We present the case of an 8-year-old boy who sustained a penetrating neck wound from an air gun. Use of the flexible laryngoscope in the resuscitation room allowed localization of the gun pellet in the airway.

CONCLUSIONS

This approach, combined with careful clinical assessment led to immediate removal by direct laryngoscopy, thus avoiding the morbidity of unnecessary surgical exploration.

Early management of the traumatized airway

Penetrating face and neck trauma is usually obvious, but blunt trauma mandates high index of suspicion to recognize its existence. Comprehensive understanding of the injury is mandatory to plan the best timing and method to secure the airway.

Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study

OBJECTIVE

The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries.

METHODS

All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck.

RESULTS

During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry.

CONCLUSION

Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.

Gunshots to the neck: selective angiography as part of conservative management

Trauma units all over the world are faced with an ever-increasing number of gunshot injuries. While the traditional view is that exploration is mandatory for all gunshot wounds to the neck, this issue is now often debated amongst trauma surgeons. The aim of this particular study was to assess the outcome of gunshot wounds to the neck using a selective conservative approach. Haemodynamically stable patients were investigated with angiography. Only when this proved to be positive, the patient was surgically explored. The records of 116 patients presenting with a gunshot to the neck to our trauma unit over a 3-year-period were reviewed. We studied demographics, bullet track, clinical findings, diagnostic investigations, methods of treatment, time in hospital and outcome. Seventy of the 116 patients sustained a direct hit to the neck, in 46 patients the bullet traversed the face or chest first. Eighty-five patients presented with vascular injury, 61 with an injury to the airway, 32 with an injury to the pharynx or oesophagus, and 12 with sustained neurological damage. Angiography was performed in 89 patients and was positive in 12 patients. Lesions occurred in the common carotid artery (seven), the internal carotid artery (three), the external carotid artery (three), the vertebral artery (two) and the subclavian artery (one). Five patients had more than one lesion. In total 18 patients were treated operatively by performing a neck exploration. Four patients had emergency surgery for exsanguinating bleed. Fourteen had surgery after a positive diagnostic study; 12 after angiography, 2 after another positive investigation. Ten (8.6%) patients died; three during resuscitation, three during emergency exploration, two due to respiratory failure, one postoperative and one from the adult respiratory distress syndrome (ARDS). Our results suggest that selective conservative management is a good treatment for gunshot wounds of the neck. In our experience angiography plays a key role in the detection of a major vascular injury requiring surgical exploration. Careful clinical assessment enhanced with the appropriate investigations is the cornerstone for deciding to explore a gunshot wound to the neck.

Facio-cervical transfixion by a metallic rod: a case report

Foreign bodies penetrating into the neck may cause extensive neurovascular and aerodigestive tract injuries. Facio-cervical transfixion by a metallic rod without such injuries is very rare. The patient presented in this article reported to our center 5 hours after the road traffic accident with impacted hollow metallic rod traversing through the tongue, pharynx, and neck after causing fracture to maxilla. Exploration under general anesthesia after tracheostomy resulted in an uneventful extraction of the metallic rod. Postoperatively, the patient recovered completely and had no neurologic deficits. [Editorial comment: This case report demonstrates an approach to an extremely difficult and potentially dangerous clinical problem. The authors decision to forego angiography is based on physical examination with evidence of palpable flow in the superficial temporal artery.]

Helical CT of cervical spine and soft tissue injuries of the neck

Helical CT of the neck has revolutionized the diagnostic evaluation of trauma and emergency room patients. This comprehensive examination, with high resolution and fast acquisition times, allows the radiologist to make expeditious diagnoses concerning cervical spine fractures, vascular injuries, and aero-digestive tract lesions. This allows for the more rapid triaging and treatment of various injuries resulting in improved patient priate radiographic examination for each clinical scenario.

Penetrating neck trauma

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.

Selective management of penetrating neck trauma based on cervical level of injury

BACKGROUND

Selective surgical exploration of penetrating neck wounds is now the standard of care, but the safety and cost effectiveness of selective diagnostic testing remains controversial. We herein review our 18-year prospective evaluation of a progressively selective approach.

PATIENTS AND METHODS

Since 1979, 312 patients sustained penetrating trauma to the anterior neck; 75% were stabbed and 24% were shot. Zone I was penetrated in 13%, zone II in 67%, and zone III in 20%.

RESULTS

In all, 105 (34%) of the patients had early exploration (16% were nontherapeutic). Of the 207 (66%) observed, 1 (0.5%) required delayed exploration. Length of stay was 8.0 days following exploration, 5.1 days following negative exploration, and 1.5 days following observation. In the last 6 years, 40% have had adjunctive testing: 69% of zone I, 15% of zone II, and 50% of zone III injuries.

CONCLUSION

Selective management of penetrating neck injuries is safe and does not mandate routine diagnostic testing for asymptomatic patients with injuries in zones II and III.

Dynamic analysis of penetrating trauma

BACKGROUND

Whereas considerable literature exists on the wounding mechanics of high velocity projectiles in the military domain, there is a paucity of such data from projectiles routinely encountered in the civilian population in the United States. This study was undertaken to develop a methodology and to determine the dynamics of penetrating trauma secondary to low velocity projectiles (200-300 m/sec). To demonstrate the feasibility of the methodology and the experimental protocol, two markedly different projectiles were chosen in the study.

METHODS

Two projectiles were discharged into a human tissue simulant; one projectile was smooth and the other was of the expansion type. High-speed video photographic analysis and synchronized trigger techniques were used to describe the path of the projectile during its travel within the simulant. The temporal transient and residual profiles demonstrating the "wound involvement" were computed.

RESULTS

Results indicated a stark contrast between the two cases. There was a ratio of approximately three-to-one in the maximum wound involvement due to penetration. Transient wave oscillations during penetration and perforation of the projectile from the tissue simulant demonstrated significant differences in amplitudes and time durations. In addition, the residual wound involvement profiles indicated differences in the injury potential.

CONCLUSIONS

This study has provided an experimental methodology to delineate the temporal dynamic behavior of penetrating projectiles. To fully quantify and differentiate the dynamic differences in the temporal behaviors of the numerous available projectiles (with various combinations in design, type of equipment, and discharge), further research in this area is clearly necessary. The present protocol lends itself to be used to systematically analyze all these behaviors. Quantified data may assist clinical personnel in the management of penetrating trauma.

Selective surgical management of zone II gunshot injuries of the neck: a prospective study

BACKGROUND

The management of penetrating neck trauma remains controversial, with many studies supporting either mandatory exploration or selective conservatism.

METHODS AND RESULTS

This is a prospective study of 75 patients with gunshot injuries to zone II of the neck. Forty patients (53.3%) underwent immediate exploration because of clinical indications or positive initial investigations. A 7.5% incidence of unnecessary explorations, a 5% mortality rate, and average hospital stay of 10.5 days were noted. Thirty-five patients with negative clinical or investigational findings underwent observation with constant monitoring. A 5.7% incidence of missed injuries, no mortality, and an average hospital stay of 3.5 days were noted for these patients.

CONCLUSIONS

We suggest that conservative management in gunshot injuries confined to zone II of the neck selectively supplemented by appropriate investigations is a viable proposition in this type of injury. Further contemporary studies reporting specifically on this injury will enable us to reach statistically significant conclusions.

Transaxial gunshot injuries

OBJECTIVE

To define the clinical characteristics of gunshot injuries across the truncal midline (transaxial injuries).

DESIGN

A retrospective case-control study

MATERIALS AND METHODS

Analysis of a consecutive series of 223 patients with gunshot injuries to the torso treated at one trauma center. Sixty-three patients with transaxial injuries were compared to 148 patients with unilateral bullet trajectories.

MAIN RESULTS

The incidence of cardiac (8%), vascular (17%), and spinal (29%) injuries and the mortality rate (29%) were significantly higher among the 63 patients with transaxial injuries compared with 148 patients with unilateral injuries. Initial operative access to the wrong visceral cavity (10%), missed injuries (14%), and early reoperations (19%) were also more common in the transaxial group.

CONCLUSIONS

A transaxial bullet trajectory identifies a distinct injury pattern associated with a high incidence of major visceral damage, intraoperative misadventures, and very high mortality.

Complex problems in penetrating neck trauma

This article discusses the problems and controversies in the assessment of penetrating injuries of the neck. The role of physical examination and color-flow Doppler imaging in the initial assessment is highlighted. Complex injuries of major vessels, the aerodigestive tract, and the parotid are discussed and therapeutic options are presented.

Transcervical gunshot injuries: mandatory operation is not necessary

BACKGROUND

It has been suggested that all transcervical gunshot wounds should be explored surgically because of the high incidence of injuries to vital structures. The present prospective study investigated the clinical presentation, the role of various diagnostic investigations, and the need for surgery in patients with transcervical gunshot injuries.

METHODS

Ninety-seven patients sustained gunshot injuries to the neck and 33 of them (34%) were transcervical. All victims were assessed clinically according to a written protocol and subsequently were evaluated angiographically, and, in the appropriate case, by means of endoscopy and esophagography.

RESULTS

Overall, 24 (73%) of the 33 patients with transcervical gunshot wounds had injuries to cervical structures. Vascular injuries were found in 48%, spinal cord injuries in 24%, and aerodigestive tract injuries in 6% of patients with transcervical injuries. In the 64 patients without midline crossing, the incidence of cervical structure injuries was 31%. Despite the high incidence of injuries to cervical structures in transcervical wounds, only 21% of the patients had a therapeutic operation. The overall mortality was 3%. There were no in-hospital deaths or local complications in the nonoperatively managed group.

CONCLUSIONS

The results of the present study do not support the current recommendations of mandatory operation for all transcervical gunshot wounds. A careful clinical examination combined with the appropriate diagnostic investigations should determine the treatment modality. About 80% of these patients can safely be managed nonoperatively.