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MANAGEMENT OF MANAGEMENT OF GUNSHOT INJURIESGUNSHOT INJURIES

Dr. MUHAMMAD YOUNASDr. MUHAMMAD YOUNASTMO ORAL SURGURYTMO ORAL SURGURY

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INTRODUCTION The greater the ignorance the greater the

dogmatism (William Osler)

The most worst injuries depending upon the range, velocity and caliber of the shot

Typically involved both soft tissue and bones

Wounds caused by gunshot lead to unique and complex injury patterns

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PHYSICS OF THE GUNSHOT WOUNDS

Wounding capacity depends upon kinetic energy impact

K.E =

Wounding power Velocity determine the wounding capacity Injury caused by a bullet is directly proportional to

the amount of energy transferred and to the actual energy expended

2

21 mv

2)( exitimpact VVmP

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MECHANISM OF GUNSHOT INJURIES

Components of projectile wounding1. Penetration (transfer destructive energy to

surrounding tissue)2. Permanent cavity formation3. Temporary cavity formation4. Fragmentation (primary, secondary)

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FACTORS AFFECTING THE DEGREE OF INJURIES

Velocity of bullet Size of bullet Drag and retardation Composition of bullet (single, multiple) shape of the bullet Extent of cavitations that occurs Deviation (yaws)

CLASSIFICATION OF GUNS ON THE BASIS OF VELOCITY

Low velocity ( 350 m/s). Medium velocity (350-600

m/s) High velocity ( 600 m/s) Velocity approximately

50 m/s is required to penetrate the skin

65 m/s fracture the bone

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Rifle has high velocity

Piston has medium velocity (hand gun)

Revolver has low velocity

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COMPOSITION OF BULLET

Shape and consistency of bullet determine the nature of wound

Bullet alloy composition 2% tin, 6% antimony and 92% lead

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FIREARM TERMENOLOGYFIREARM TERMENOLOGY

BALLISTICS BALLISTICS (science of projectile motion)(science of projectile motion) Relating to or characteristic of the motion of objects moving under Relating to or characteristic of the motion of objects moving under

their own momentum and the force of gravity; "ballistic missile" their own momentum and the force of gravity; "ballistic missile"

Handguns (pistol, revolvers)Handguns (pistol, revolvers)

Rifles Rifles

ShotgunsShotguns

Yaw (oscillation around the long axis of the bullet)Yaw (oscillation around the long axis of the bullet)

Precession (circular yawning)Precession (circular yawning)

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CLASSIFICATION OF GUNSHOT CLASSIFICATION OF GUNSHOT WOUNDSWOUNDS

1.1. Based on the velocity (energy transferred)Based on the velocity (energy transferred)

Low energy transfer woundsLow energy transfer wounds

High energy transfer woundsHigh energy transfer wounds

Middle energy transfer woundsMiddle energy transfer wounds

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CLASSIFICATION OF GUNSHOT CLASSIFICATION OF GUNSHOT WOUNDSWOUNDS

2.2. Simplest classification schemeSimplest classification schemeA.A. Penetrating woundsPenetrating wounds low velocity projectilelow velocity projectile embedded in the tissueembedded in the tissue small point of entrysmall point of entry Examples handguns bullet (release energy Examples handguns bullet (release energy

100-500J)100-500J)B.B. Perforating woundsPerforating wounds High velocity (high energy transfer wounds)High velocity (high energy transfer wounds) Exit wound larger than entryExit wound larger than entry In and outIn and out Examples rifles bullet woundsExamples rifles bullet wounds

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C.C. Avulsive woundsAvulsive wounds Loss of tissueLoss of tissue Irregular fragments from bombs Irregular fragments from bombs grenadesgrenades3.3. Gugala and Lindsey classificationGugala and Lindsey classification

1.1. High or low energy woundsHigh or low energy wounds2.2. Involvement of vital structure (neural Involvement of vital structure (neural and vascular)and vascular)3.3. Wound type (non-penetrating, Wound type (non-penetrating, penetrating, perforating)penetrating, perforating)4.4. Fracture (intra-articular and extra-Fracture (intra-articular and extra- articular)articular)5.5. contaminationcontamination

CLASSIFICATION OF GUNSHOT CLASSIFICATION OF GUNSHOT WOUNDSWOUNDS

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Avulsive wounds

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Wounds

ENTRY WOUND

Smaller size

If at contact blast skin

.

Inverted margins.

Abrasion collar present

EXIT WOUND

tear of tissues

Split outward skin

Everted margins

Abrasion collar absent

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Wounds

ENTRY WOUND

Burning /blackening /singing /tattooing seen

Laed ring seen

EXIT WOUND

No such phenomenon seen

Lead ring not seen

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Left neck entry pointLeft neck entry point

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MANAGEMENTMANAGEMENTGeneral principles (ATLS protocol)General principles (ATLS protocol)

Rule out (look for) Rule out (look for)

multiple injurymultiple injury

inspection of entrance and exit point inspection of entrance and exit point (multiple)(multiple)

Penetrating, perforating, avulsive Penetrating, perforating, avulsive woundswounds

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MANAGEMENTMANAGEMENT

17 % patient of GSW to the face 17 % patient of GSW to the face have associated have associated brain injuriesbrain injuries

8 % C-spine injuries8 % C-spine injuries

13 % eye injuries13 % eye injuries

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EMERGENCY TREATMENT OR EMERGENCY TREATMENT OR IMMIDIATE POST TRAMATIC PHASEIMMIDIATE POST TRAMATIC PHASE

A.A. AIRWAY (single most cause of death AIRWAY (single most cause of death in GSW to the in GSW to the face)face)

Emergency intubations (25-36%)Emergency intubations (25-36%) Mandible wounds rate of intubations (37-Mandible wounds rate of intubations (37-

53%)53%) Mid face (18-36%)Mid face (18-36%) Cricothyroidotomy (tracheal)Cricothyroidotomy (tracheal) tracheostomytracheostomy

B.B. BreathingBreathingC.C. circulationcirculation

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D.D.Hemorrhage ControlHemorrhage Control– Direct pressureDirect pressure

– PackingPacking

– Epistaxis control (foley, balloon catheters)Epistaxis control (foley, balloon catheters)

– Reductions of fracture segmentReductions of fracture segment

– Angiography and embolizationAngiography and embolization

– Ligation and tying offLigation and tying offEE.. AnalgesiaAnalgesia

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IMMAGING Plain Radiographs

1. C-spine views2. Chest radiograph3. PA view of face4. Lateral view of face5. PNS (water) view

CT scan 3-D CT scan CT-Angiography ultrasonography

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KAZANJIAN -PHASE APPROACH (MANGMENT)

PRIMARY SURGICL PHASEA. Wound toilet

B. Conservative debridement (removal of devitalize tissue)

C. Removal of teeth (extensive damage)

D. Wound evaluation and exploration

E. Primary surgical reconstructionimmobilization of bony fragments

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KAZANJIAN -PHASE APPROACH (MANGMENT)

Recons plates MMF External pin fixation Archbar Splint

F. Closure of skin and mucosa(local flaps-grafts)

G. Drainage (contaminated wounds)

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CONTAMINATION• All gunshot wounds are contaminated

• Missile fragment, bullet, lodged in tissue leads to abscess formation

• Intra-articular bullet fragments and bullet near to nerves should removed

• Projectiles from gunshot are not sterile

• Prophylactic antibiotics plus tetanus prophylaxis indicated

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Radiopaque mass in the sinusRadiopaque mass in the sinus

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(KAZANJIAN -PHASE APPROACH (MANGMENT)

IMMIDIATE POST OP PHASE

Reassure sympathetic nursingSpecial feeding deviceSaliva shieldMouth washesTracheostomy care

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KAZANJIAN -PHASE APPROACH (MANGMENT RECONSTRUCTIVE PHASE

First surgery reduce later reconstructionSkin grafting (immediate)Bone grafting

Mid face (immediate/primary reconstruction)Mandible (late reconstruction) but mandibular

segment is maintained with plateTeeth prosthesis (late)

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FUNCTIONAL RECONSTRUCTION

Ridge augmentation

Dental implants

Scar revision

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GOALS OF RECONSTRUCTION• Restoration of function

• Rebuilding of facial feature and improvement of appearance

• Preparation of patient to re enter in society

• Improvement of psychodynamics

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EARLY RECONSTRUCTION

ADVANTAGES Early stabilization and support of soft tissue Decrease scar contracture No secondary surgery No long term facial deformity

DISADVANTAGES Infection Lack of tissue for proper covering Long operating time Loss of bone graft

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DELAYED RECONSTRUCTION

ADVANTAGES Satisfactory result in appearance and function less chance of infection Implant can be placed Patient afford second surgery Decrease chance of failure of reconstruction

DISADVANTAGES Loss of facial deformity Scar revision

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GRAFT SOURCESGRAFT SOURCES

BONE GRAFT SOURCESBONE GRAFT SOURCES

RibsRibs

Illiac graftIlliac graft

fibula fibula

CalvariumCalvarium

Alloplastic bone materialAlloplastic bone material

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ASSESSMENT OF PATIENT FOR RECONSTRUCTION

1. Hard tissue defect

Radiographs for assessment of extent of defect

Site of defect

Size of defect

2.Position of residual fragments

3.Assessment of soft tissue bed

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DIFFERENT FLAPS

Pedicle flapsA. Local flaps

1. mucosal 2. skin3. fats

B. Distant flaps1. fasciocutaneous

2. myocutaneous Free flaps (totally removed

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SPECIALIZED SRUCTURE DAMAGE

1. Facial nerve (3-6%) GSWa. Contaminated wounds repair delayed for 48-72 hrs

b. Repair should be made in initial surgical procedure.

c. should not be delayed more than a months

2. Salivary ducta. Repaired or ligated (intravenuse catheter or polymericsilicone tubing

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MANAGEMENT OF SALIVARY FISTULAE: (A Classification of Reported Methods in the Literature)

1. Diversion of secretion into the mouth

A. Reconstructive methods Delayed primary repair of duct

Reconstruction of duct with vein graft

Mucosal flaps

Suture of proximal duct to buccal mucosa

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B. Formation of a controlled internal fistula

T-tube or catheter drainage into the mouth Drainage of proximal duct by a catheter

C. gland removalD. Local therapy to the fistula

Excision Cauterization

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2. Depression of secretion

A. Surgical approaches

Duct ligation Sectioning of the auricotemporal or Jacobsen's nerve

B. Conservative approaches

Administering nothing orally to the patient until the fistula closes Drugs: atropine or Pro-banthine Radiotherapy Repeated aspiration and pressure dressing

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PENETRATING NECK INJURIESPENETRATING NECK INJURIES GSW of the face may be associated with entrance and exit wound in the GSW of the face may be associated with entrance and exit wound in the

neck.neck.

MONSANS Zones of the neck.MONSANS Zones of the neck.Zone 1;area from clavicle to cricoid Zone 1;area from clavicle to cricoid cartilage (mortality 12 %)cartilage (mortality 12 %)

Contents Contents – A.A. carotid arteriescarotid arteries– B.B. subclavian arteries and veinssubclavian arteries and veins– C.C. internal jugular veinsinternal jugular veins– D.D. thoracic duck, esophagus thoracic duck, esophagus – E.E. thyroid gland, tracheathyroid gland, trachea– F.F. brachiocephalic trunk etcbrachiocephalic trunk etc

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ZONE-2ZONE-2

Area from cricoid cartilag to the angle of mandibleArea from cricoid cartilag to the angle of mandible

ContentsContents Common carotid arteries Common carotid arteries

Internal and external carotid arteriesInternal and external carotid arteries

Internal jugular veinsInternal jugular veins

Larynx Larynx

Cranial nerves X, IXCranial nerves X, IX

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ZONE-3 (From Skull Base To The ZONE-3 (From Skull Base To The Angle Of Mandible)Angle Of Mandible)

ContentsContents– Carotid arteriesCarotid arteries

– Internal jugular veinsInternal jugular veins

– Cranial nervesCranial nerves

Mandibular fractures accompanied by injuries to zone-3Mandibular fractures accompanied by injuries to zone-3

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Airgun pellet deep to external carotid artery

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MANAGEMENT OF ZONEPENETRATING NECK WOUNDS

• ATLS protocol for airway

• Primary survey

• Secondary survey (rule out hard sign of vascular and laryngotracheal injury)

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MANAGEMENT OF ZONE• Symptomatic patient

• Zone-1 perform angiography followed by neck exploration

• Direct essophagoscopy vs postoperative barium swallow

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• Zone-2 (symptomatic patient)

Check hard signs

Neck exploration. Asymptomatic patient

Advise computed tomographic angiography

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ZONE-3• Perform angiography• • Perform interventional radiology

• Neck exploration

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CHYLE LEAK MANAGEMENT

Intra-operative Apply continues positive pressureLigation of thoracic ductSclerosing agent

post opHigh output 400-500cc/dRe-exploration of neck Trendelenburg’s positionSclerosing agent

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Low outputAspirationDressingDiet of medium chain triglycerides

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THANKS……