Current treatment procedures for civilian gunshot wounds

Česká verzia

Authors: Martin Vlček ¹ ; E. Jaganjac ¹; M. Niedoba ¹; I. Landor ¹; J. Neumann ²
Authors place of work: Ortopedická klinika 1. lékařské fakulty Univerzity Karlovy Praha a Fakultní nemocnice Motol ¹; Chirurgická klinika 2. lékařské fakulty Univerzity Karlovy Praha a Fakultní nemocnice Motol ²
Published in the journal: Rozhl. Chir., 2018, roč. 97, č. 12, s. 558-562.
Category: Původní práce

Summary

Introduction:

This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment.

Method:

We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 18−71). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established.

Results:

Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve.

Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal.

Conclusion:

Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious.

Key words:

gunshot wound – civilian settings − surgical treatment

Zdroje

Norton J, Whittaker G, Kennedy DS, et al. Shooting up? Analysis of 182 gunshot injuries presenting to a London major trauma centre over a seven-year period. Ann R Coll Surg Engl 2018;100:464−74.
Peponis T, Kasotakis G, Yu J, et al. Selective nonoperative management of abdominal gunshot wounds from heresy to adoption: A multicenter study of the research consortium of New England centers for trauma (ReCoNECT). J Am Coll Surg 2017;224:1036−45.
Jaganjac E, Kuba T, Višňa P, et al. Ošetření střelných poranění a prevence vzniku komplikací v průběhu hojení. Rozhl Chir 2007;86:188−93.
Klein L, Ferko A. Principy válečné chirurgie. Praha, Grada Publishing 2005.
Dragović M, Todorović M. Urgentna iratna hirurgija. Bělehrad, Serbia, Velarta 1998:60−4.
von See C, Rana M, Stoetzer M, et al. A new model for the characterization of infection risk in gunshot injuries: technology, principal consideration and clinical implementation. Head Face Med 2011;7:18.
Arunkumar KV, Kumar S, Aggarwal R, et al. Management challenges in a short-range low-velocity gunshot injury. Ann Maxillofac Surg 2012;2:200−3.
Golema W, Jurek T, Thannhäuser A, et al. Possibilities of energy augmentation of pellets shot from ASG replicas and gunshot wounds. Arch Med Sadowej Kryminol 2011;61:313−8.
Čečka F, Asqar A, Jon B, et al. Střelná poranění dutiny břišní zasahující pankreas. Acta Chir Orthop Traumatol Cech 2012;79:455−8.
Partin C. Vulnus sclopetarium (gunshot wound). Proc (Bayl Univ Med Cent) 2018;31:231−4.
Lounsbury D, Brengman M, Bellamy R. Emergency war surgery. 3rd edition Washington DC, Borden institute, Walter Reed Army medical center 2004.
Dozič, Š. Savremeni principi ratne hirurgije u liječenju preloma extremiteta. Sarajevo, Medicinski bilten. Državna bolnica 1993:21.
Byrne A, Curran P. Necessity breeds invention: a study of outpatient management of low velocity gunshot wounds. Emerg Med J 2006;23:376–8.
Bartlett CS, Helfet DL, Hausman MR, et al. Ballistics and gunshot wounds: effects on musculoskeletal tissues. J Am Acad Orthop Surg 2000;8:21−36.
Kinch KJ, Clasper JC. A brief history of war amputation. J R Army Med Corps 2011;157:374−80.
Ali MA, Hussain SA, Khan MS. Evaluation of results of interlocking nails in femur fractures due to high velocity gunshot injuries. J Ayub Med Coll Abbottabad 2008;20:16−9.
Softah AL, Eid Zahrani M, Osinowo O. Gunshot injuries in adults in the Abha region of Saudi Arabia. Afr J Med Med Sci 2002;31:41−4.
Salim A, Velmahos GC. When to operate on abdominal gunshot wounds. Scand J Surg 2002;91:62.
Fikry K, Velmahos GC, Bramos A, et al. Successful selective nonoperative management of abdominal gunshot wounds despite low penetrating trauma volumes. Arch Surg 2011;146:528−32.
Hope WW, Smith ST, Medieros B, et al. Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center? J Emerg Med 2012;43:190−5.
İflazoğlu N, Üreyen O, Öner OZ, et al. Non-operative management of abdominal gunshot injuries: Is it safe in all cases? Turk J Surg 2018;34:38−42.
Yilmaz TH, Ndofor BC, Smith MD, et al. A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries. Scand J Trauma Resusc Emerg Med 2010;18:40.
Scialpi M, Magli T, Boccuzzi F, et al. Computed tomography in gunshot trauma. I. Ballistics elements and the mechanisms of the lesions. Radiol Med 1995;89:485−94.
Ordog GJ, Wasserberger J, Balasubramanium S, et al. Civilian gunshot wounds-outpatient management. J Trauma 1994;36:106−11.