Pathogenesis and treatment of gunshot wounds of soft tissues

Based on experimental investigations and generalization of the experience with treatment of wounds the authors pay attention to principal distinctions of the gunshot wound from other kinds of open injuries, as well as to the importance of early primary surgical treatment of the gunshot wound in prophylactics of infectious complications. Data on possible use of microwave radiation and medicamentous agents for stabilization of the wound process and restriction of spread of the secondary necrosis++ are presented.     

Treatment of complex below-the-elbow gunshot wounds

Firearm injuries, many of which involve the hand, wrist, or forearm, pose a serious public health concern in the United States in both medical and economic terms. Despite the preponderance of low-velocity weapons, complex below-the-elbow gunshot injuries are commonly seen. A successful approach to these patients requires efficient treatment and early initiation of rehabilitation. Unfortunately, this goal is often not met because of multiple factors including wound infections, the need to coordinate multiple surgical specialties, long hospital stays, and delayed definitive reconstruction. At our institution, the plastic surgery hand service is able to treat all aspects of below-the-elbow trauma. A protocol of early aggressive debridement and skeletal stabilization, with definitive reconstruction within 1 week of injury, is used. We retrospectively reviewed all complex below-the-elbow gunshot injuries treated by the senior author between 1996 and 2003. Eighteen such patients were identified. All limbs were salvaged and all patients regained functional use of the extremity. There was no incidence of wound infection. The average length of inpatient stay was 8.9 days (median, 7 days). The use of this protocol by a single surgical specialty allows efficient reconstruction, short hospital stays, and early initiation of rehabilitation.     

Ballistics and gunshot wounds: effects on musculoskeletal tissues

As a result of the increasing number of weapons in this country, as many as 500,000 missile wounds occur annually, resulting in 50,000 deaths, significant morbidity, and striking socioeconomic costs. Wounds are generally classified as low-velocity (less than 2,000 ft/sec) or high-velocity (more than 2,000 ft/sec). However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as kinetic energy, stability, entrance profile and path traveled through the body, and the biologic characteristics of the tissues injured. Although bullets are not sterilized on discharge, most low-velocity gunshot wounds can be safely treated nonoperatively with local wound care and outpatient management. Typically, associated fractures are treated according to accepted protocols for each area of injury. Treatment of low-velocity, low-energy fractures is generally dictated by the osseous injuries, as these are similar in many regards to closed fractures. Soft tissues play a more critical role in high-velocity and shotgun fractures, which are essentially open injuries. Aside from perioperative prophylaxis, antibiotics are probably required only for grossly contaminated wounds; however, because contamination is not always apparent, most authors still recommend routine prophylaxis. High-energy injuries and grossly contaminated wounds mandate aggressive irrigation and debridement, including a thorough search for foreign material. Open fracture protocols including external fixation or intramedullary nailing and intravenous antibiotic therapy for 48 to 72 hours should be instituted. If there is vascular damage, exploration and repair are best performed after prompt fracture stabilization. Evaluation of the "four Cs"-color, consistency, contractility, and capacity to bleed-provides valuable information regarding the viability of muscle. Skin grafting is preferable when tension is required for wound closure, although other soft-tissue procedures, such as use of local rotation flaps or free tissue transfer, may be necessary, especially for shotgun wounds. Distal neurologic deficit alone is not an indication for exploration, as it often resolves without surgical intervention.     

Treatment of civilian gunshot wounds to the head

Gunshot wounds to the head are a common problem in the United States. A review of the literature and a survey of neurosurgeons suggests some differences of opinion regarding treatment. But the series upon which these opinions are based may be quite different. Disseminated intravascular coagulation can be a major problem. CT scanning is important for surgical decision making. Angiography should be used in cases in which bullets have passed near major vessels. We suggest an aggressive approach, with evacuation of clots and monitoring of intracranial pressure and treatment of elevations, as well as the routine use of anticonvulsants and antibiotics. Vocational rehabilitation is also important.     

Treatment strategies for gunshot wounds of the extremities

The incidence of gunshot wounds is increasing also in Europe and surgeons in urban trauma centers are more frequently confronted with this type of injury. Since there is no established treatment algorithm for gunshot injuries to the extremities, the surgeon should rely on established soft tissue injury and fracture protocols. Gunshot fractures with minor soft tissue destruction should be treated as closed fractures. The treatment of choice for unstable fractures is early internal stabilization, whereas stable fractures may be treated by functional bracing. The administration of an antibiotic prophylaxis for fractures with minor soft tissue injury is controversial. Gunshot fractures with major soft tissue injury should be treated as open fractures. Debridement of nonviable tissue and external fixation are recommended. Prophylactic intravenous antibiotics are mandatory and prophylactic fasciotomy is often required. Upon definitive internal stabilization, bone grafting should be considered since gunshot fractures are usually associated with a high degree of comminution. Articular gunshot injuries are treated as open joint injuries and require irrigation, debridement, foreign body removal and antibiotic prophylaxis.     

Cranial gunshot wounds

Cranial gunshot wounds frequently produce devastating injuries to central nervous system structures. This article reviews pertinent principles of ballistics to explain several mechanisms of injury to the brain. A series of 21 consecutive cases of cranial gunshot wounds is presented outlining a protocol for management and identifying factors of prognostic significance.     

Liver gunshot wounds

The paper presents the 6 cases of liver shot wounds that were in supervision of the general surgery unit, County Hospital of Baia Mare, between the years 1990-1997. The patients were males, most of them being 20 to 30 years old. In 3 situations hunting rifles were involved, all followed by retention of metal foreign body. The wounds were plurivisceral in 5 of the 6 cases, the most frequently wounded was the right liver lobe. All the patients presented serious traumatic shock and haemorrhagic shock. Livertectomy was used in 40% of the cases being imposed by the dilacerant and transfixiant character of the wounds and also by the retention of foreign bodies in parenchime. We registered 2 demises, both in the first postoperatory hours. The paper proposes a few criteria that allow the application of a conservatory treatment:rapid favourable answer at deshocking therapy; hemodynamic stability; minimal hemoperitoneus (echographical and tomographical); absence of associated visceral wounds or, when they exist, of serious physiopathological consequences; access to performant means of imagistics.     

Civilian gunshot wounds

A wide variety of injuries are encountered in civilian gunshot wounds with the severity directly related to the amount of kinetic energy imparted on the tissues. A surgeon should be aware of the different ballistic properties of the various firearms and be prepared to treat each patient as an individual. Furthermore, the physician should be attentive to severe complications that may occur even after appropriate treatment has been given. During an 18 month period on the LSU Surgical Service, 431 patients were admitted for gunshot wounds of which 218 had extremity injuries. One hundred seventy of these patients were evaluated and surveyed for type of injury, surgical procedure, and complications relating to the velocity of the involved.     

Treatment of peace-time thoracic and abdominal gunshot wounds]

The article analyses the results of treatment of gunshot injuries to the chest and abdomen suffered by 59 males in peace time. Their ages ranged from 17 to 51 years. It was found that gunshot injuries to the chest and abdomen suffered in peace time are characterized by a severe clinical course, multiple damages of polyorganic localization, they are often attended by shock and are marked by a great number of pyoseptic complications and a high mortality rate, particularly in concurrent and combined injuries to the organs of both cavities.     

Treatment of purulent-inflammatory complications of the soft tissues wounds in elderly and senile patients

Experience of treatment of elderly and senile patients with purulent infection of the soft tissues wounds was summarized. For raising of the therapeutic effect of the local treatment the introduction of new combined medicinal forms, composition of which was scientifically substantiated according to the wound process pathogenesis with special attention to its phase and character of microflora (kind of microorganism and its sensitivity to antimicrobic agents), is perspective.     

Treatment and diagnostic policy in gunshot wounds of the pancreas

Results of treatment of 71 patients with gun-shot wounds of the pancreas were analyzed. Features and structure of gun-shot abdominal penetrating wounds with injury of the pancreas, potential of up-to-date diagnostic methods were studied. Surgical policy in combined injuries of hollow organs and pancreas was developed. Variants and sequence of surgeries were determined depending on location and types of pancreatic injuries. Proposed treatment and diagnostic policy permitted to reduce rate of purulent and septic complications by 11.1% and lethality by 5.3%.