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Dehne LM, Foertsch MJ, Droege CA, Makley AT, Mosher DR, Philpott CD, Sagi HC, Mueller EW, Droege ME. Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience. J Surg Res 2023; 291:97-104. [PMID: 37354706 DOI: 10.1016/j.jss.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.
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Affiliation(s)
- Lauren Michelle Dehne
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio.
| | - Madeline Jane Foertsch
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Christopher Allen Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Amy Teres Makley
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Carolyn Dosen Philpott
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Henry Claude Sagi
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric William Mueller
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Molly Elizabeth Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
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Tisnovsky I, Katz SD, Pincay JI, Garcia Reinoso L, Redfern JAI, Pascal SC, Wham BC, Naziri Q, Suneja N. Management of gunshot wound-related hip injuries: A systematic review of the current literature. J Orthop 2020; 23:100-106. [PMID: 33488004 DOI: 10.1016/j.jor.2020.12.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To propose a gunshot wound-related hip injury algorithm and improve patient outcomes. Methods Multiple online databases were queried to identify studies reporting on management of gunshot-wound hip injury. Results Of 47 papers included, 5 and 14 studies recommended surgical intervention for the treatment of low- and high-velocity gunshot wounds, respectively, and 1 paper advocated the use of prophylactic antibiotics in the treatment of high-velocity injuries. All remaining papers had mixed and conflicting results. Conclusion Various therapeutic strategies have been used for the management of gunshot wound-related hip injuries but further prospective studies are necessary to determine the optimal therapeutic modality.
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Affiliation(s)
- Ilene Tisnovsky
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Simon D Katz
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Jorge I Pincay
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Lucas Garcia Reinoso
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - James A I Redfern
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Scott C Pascal
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Bradley C Wham
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
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Gupta AK, Edwards B, Vega JA. The Tumbling Bullet: Subacute Intestinal Obstruction due to a Retained Bullet. Cureus 2020; 12:e9844. [PMID: 32953351 PMCID: PMC7497767 DOI: 10.7759/cureus.9844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
A 29-year-old female presented with multiple gunshot wounds to the back and bilateral lower extremities. The patient underwent an exploratory laparotomy with small-bowel resection of two segments with primary stapled anastomosis and partial nephrectomy. The postoperative course showed prolonged intermittent bowel obstruction secondary to the bullet, which lodged in the distal ileum. The patient eventually passed the bullet; it, however, led to a delay in recovery.
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Affiliation(s)
- Anupam K Gupta
- Minimally Invasive Surgery, University of Miami Hospital, Miami, USA
| | - Blake Edwards
- General Surgery, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, USA
| | - Jorge A Vega
- Trauma and Acute Care Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, USA
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Erdman MK, Munger AM, Brown M, Schellenberg M, Tucker D, Inaba K, Fleming ME, Marecek GS. Injury and treatment patterns of ballistic pelvic fractures by anatomic location. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:111-119. [PMID: 32720105 DOI: 10.1007/s00590-020-02744-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries. METHODS A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality. RESULTS Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance. CONCLUSIONS This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mary Kate Erdman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Alana M Munger
- Yale Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Meghan Brown
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Douglass Tucker
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Yale Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Mark E Fleming
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Abstract
Firearm injuries are a major cause of morbidity and mortality among children and adolescents in the United States and take financial and emotional tolls on the affected children, their families, and society as a whole. Musculoskeletal injuries resulting from firearms are common and may involve bones, joints, and neurovascular structures and other soft tissues. Child-specific factors that must be considered in the setting of gunshot injuries include physeal arrest and lead toxicity. Understanding the ballistics associated with various types of weaponry is useful for guiding orthopaedic surgical treatment. Various strategies for preventing these injuries range from educational programs to the enactment of legislation focused on regulating guns and gun ownership. Several prominent medical societies whose members routinely care for children and adolescents with firearm-related injuries, including the American Academy of Pediatrics and the American Pediatric Surgical Association, have issued policy statements aimed at mitigating gun-related injuries and deaths in children. Healthcare providers for young patients with firearm-related musculoskeletal injuries must appreciate the full scope of this important public health issue.
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Sathiyakumar V, Thakore RV, Stinner DJ, Obremskey WT, Ficke JR, Sethi MK. Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices. Curr Rev Musculoskelet Med 2015; 8:276-89. [PMID: 26047781 PMCID: PMC4596195 DOI: 10.1007/s12178-015-9284-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.
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Affiliation(s)
- Vasanth Sathiyakumar
- />Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University Medical Center, Vanderbilt University, Suite 4200, South Tower, MCE, Nashville, TN 37221 USA
| | - Rachel V. Thakore
- />Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University Medical Center, Vanderbilt University, Suite 4200, South Tower, MCE, Nashville, TN 37221 USA
| | - Daniel J. Stinner
- />Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University Medical Center, Vanderbilt University, Suite 4200, South Tower, MCE, Nashville, TN 37221 USA
| | - William T. Obremskey
- />Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University Medical Center, Vanderbilt University, Suite 4200, South Tower, MCE, Nashville, TN 37221 USA
| | | | - Manish K. Sethi
- />Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University Medical Center, Vanderbilt University, Suite 4200, South Tower, MCE, Nashville, TN 37221 USA
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Riehl JT, Sassoon A, Connolly K, Haidukewych GJ, Koval KJ. Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review. Clin Orthop Relat Res 2013; 471:3956-60. [PMID: 23982410 PMCID: PMC3825878 DOI: 10.1007/s11999-013-3260-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances. QUESTIONS/PURPOSES We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments? METHODS A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included. RESULTS No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal. CONCLUSIONS The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.
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Affiliation(s)
- John T. Riehl
- />University of Louisville Hospital, Louisville, KY USA
| | - Adam Sassoon
- />Orlando Regional Medical Center, Orlando, FL USA
| | | | | | - Kenneth J. Koval
- />Orlando Regional Medical Center, Orlando, FL USA , />Level One Orthopedics, 1222 S Orange Avenue, Orlando, FL 32806 USA
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Dienstknecht T, Horst K, Sellei RM, Berner A, Nerlich M, Hardcastle TC. Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons. Eur J Trauma Emerg Surg 2011; 38:89-93. [PMID: 26815824 DOI: 10.1007/s00068-011-0170-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices. METHODS We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature. RESULTS 145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds. CONCLUSIONS In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.
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Affiliation(s)
- T Dienstknecht
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany.
| | - K Horst
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany
| | - R M Sellei
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany
| | - A Berner
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - M Nerlich
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - T C Hardcastle
- Departments of Health KZN and Surgery, Trauma Service, University of Kwazulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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