The management of shotgun wounds

Peripheral Arterial Injuries with Gunshot Wounds: Surgical Treatments and Results

Between 1975 and 1985, 102 consecutive patients with 106 peripheral vascu lar injuries caused by gunshot blasts were treated in the authors' clinic. The average age was 25.6 ± 11.4 (mean ± SD). The average time between arterial injury and arrival to the hospital was 13.2 ± 4.8 hours. Sixty-six (62.3%) arte rial injuries were found in lower extremities and the most commonly injured artery was the superficial femoral artery. Thirty-six (35.3%) patients had com bined arterial and venous trauma. All patients with vascular involvement had some signs and symptoms of vascular trauma. Preoperative angiography was required in 23 cases and demonstrated arterial injury; 98 patients underwent surgical intervention. Resection of the injured arterial segment and end-to-end anastomosis were done in 44 patients. Resection of the arterial segment followed by interposition of autogenous vein graft was done in 34 patients. One case underwent nonbiologic graft (Dacron) replacement (in the left subclavicular ar tery). Primary lateral suture was placed in 6 cases, and ligation was made in 9. In cases associated with venous injury, 22 vascular venous repairs and 14 liga tions were done. Eighty-one (79.4%) patients retained a functional limb. Two cases underwent primary amputation, and 9 cases underwent secondary ampu tation. Six patients died; the causes of morbidity were usually related to associ ated injuries. Four patients refused the surgical approach.

Thoracoabdominal shotgun wounds: an evaluation of factors associated with the need for surgical intervention

BACKGROUND

Shotgun wound classification systems attempt to predict the need for surgical intervention based on the size of wounds, pellet spread, or distance from the weapon rather than clinical findings.

METHODS

A 5-year retrospective review of patients sustaining a thoracoabdominal shotgun wound was performed. Factors believed to be associated with the need for surgical intervention were examined using the Fisher exact test or an independent sample t test.

RESULTS

Sixty-four patients suffered a thoracoabdominal shotgun wound. Fifty-nine percent required surgical intervention. Factors significantly associated with the need for surgical intervention were a low revised trauma score and systolic and diastolic blood pressure (P < .05). Distance from attacker, wound patterns, pellet size, and pellet spread were not found to have an association.

CONCLUSIONS

Clinical indicators of hemorrhage and shock are associated with the need for surgical intervention, whereas pellet spread, pellet size, and distance from the attacker are not. This is a significant departure from traditional classification systems.

Gunshot wounds of the foot

It is imperative that the physician participating in the care and treatment of foot and ankle trauma appreciate the epidemiology, the unique characteristics, and principles of treatment of gunshot injuries involving the foot and ankle. The current author will provide the reader with knowledge of how the bullet velocity, its mass, and its area are important in determining the energy transmitted to the tissues struck by the bullet. These forces imparted by the projectile interact with the specific characteristics of the tissues to determine the nature and extent of the trauma sustained by the foot and ankle. An understanding of the appropriate grading of the injury will allow for a rationale approach to the treatment of these injuries. The hallmark of treatment includes rigid skeletal fixation, revascularization, and treatment of soft tissues including appropriate wound coverage techniques.

Management and outcome of abdominal shotgun wounds. Trauma score and the role of exploratory laparotomy

OBJECTIVE

The management and outcome of 138 abdominal shotgun wounds were examined over a 5-year period.

SUMMARY BACKGROUND DATA

It has been proposed that exploratory laparotomy may be unnecessary and even overused in a subset of patients with abdominal shotgun wounds.

METHODS

Data on shotgun wound patients from October 1987 through March 1992 from a statewide trauma registry were examined. Patients with abdominal shotgun wounds were identified and compared with patients with nonabdominal shotgun wounds.

RESULTS

Of 516 shotgun wound patients, 138 (26.7%) had abdominal wounds and 88 (63.8%) had exploratory laparotomies. Abdominal shotgun wounds resulted in significantly longer number of intensive care unit days (4.3 vs. 2.5, p < 0.05), a greater number of blood units transfused (7.8 vs. 2.4, p < 0.05), and a higher mortality (15.9% vs. 4.8%, p < 0.05) when compared with nonabdominal shotgun wounds. When stratified for trauma score, the mortality for abdominal shotgun wounds always was significantly greater than for nonabdominal shotgun wounds. All abdominal shotgun wound patients with trauma scores less than ten died. The negative laparotomy rate for abdominal shotgun wound patients with normal trauma scores was 9.4%. No patient with a negative laparotomy died.

CONCLUSION

Abdominal shotgun wounds are a particularly lethal subset of shotgun wounds. Although some abdominal shotgun wound patients can be managed without laparotomy, the morbidity and mortality for these injuries are substantial, even in patients with normal trauma score. Clinical judgment is an excellent predictor of the need for laparotomy.

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 devitalized 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.

Gunshot injuries of the urinary tract

Five cases of gunshot injuries to the kidney, ureter, bladder, urethra and male external genitalia are reported. One case required nephrectomy. The others regained normal genitourinary function after surgical repair and/or adequate drainage and splintage.

Civilian maxillo-facial gunshot injuries

Recently, in many parts of the world, there has been an increase in the number of civilian crimes involving guns and nowadays any oral surgeon in hospital may be confronted with this type of injury. This paper reviews the mechanism of wounding by different firearms to allow an appreciation of their effect on living tissues, and then outlines the clinical management of these injuries.

Abdominal trauma

Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.