Case Report

Young Male presents via E.M.S. with report of Gun Shot Wound “GSW to the Chest”

• Down-Time: “5 - 8 Minutes”

• E.M.S. Arrival to Field: No Pressure, No Pulse, Pupils Fixed

• CPR Initiated; Lines Placed

• Arrived at MMC, 1945 (“10 Minutes”)

In the Trauma Room

• CPR in progress w/ Bag-Mask Ventilation

• Airway is established per Anesthesia

• No Appreciable Breath Sounds to Right Chest: 36 Fr. Chest Tube placed - obvious hemothorax

• No Pulse, No Pressure, Pupils Fixed & Dilated, GCS 3

• ACLS Protocol Followed: Fluids, Epinephrine, Atropine

• • Wounds: 1 Entry Site at 2 - 3 cm below the nipple in the midclavicular line

  • No Obvious Exit Site !

  • 1952: Carotid Pulse Palpated

  • BP: 183/106

  • P: 120 - sinus rhythm

  • 1954: Entered the Operating Room

The Operating Room

• Right Anterolateral Thoracotomy Right Lower Lobe with “through-and through track” Majority of the Right Hemidiaphraghm Missing Right Lobe of the Liver Emusified: Temporary Compression

• Midline Abdominal Incision and All Quadrants Packed Liver Compressed via “Pringle Manuver” Large Amount of Retrohepatic Bleeding

• Left Anterolateral Thoracotomy Descending Aorta Cross-Clamped

• Proximal Control !!

• • Minimal Blood or Injury to the Left Chest

  • “Bookshelf Incision”

  • Any Role for Median Sternotomy ?

  • Distal Control ?

• Distal Control: The Abdomen - IVC !

• Right Hepatectomy & Cholecystectomy

• Oversewing of the Retrohepatic IVC

Massive Bleeding relatively Controlled but - Asystole.Coded !
Internal Massage / Intracardiac Epinephrine & Cardioversion Pulse & Pressure Return

• Oversewing of the Gastric Antrum

• Multiple Enterotomies - Stapled via GIA

• Right Colectomy

Large Amount of Bleeding noted to the Right Perinephric Area !

• Right Nephrectomy

Asystole ......... Coded !

Internal Massage / Intracardiac Epinephrine & Cardioversion Pulse & Pressure Return

• Significant Bleeding now noted from the chest !

• Exploration

• Right Lower Lobe Wedge Resection but still with Active Bleeding from the Hilum

Right Pneumonectomy

• Now Bleeding at the Junction of IVC & RA probably a secondary tear from resuscitative efforts

• • V. Tach

  • Asysytole

  • Internal Massage, Epinephrine, Calcium

  • Cardioversion: Asystole

  • No Pulse, No Pressure – Sustained

  • No Evidence of Electrical Activity

  • Code Called: 2134

Sustained Injuries from a Single GSW to the Right Chest:

Operative Time: 1 hr. 39 minutes

• 14 units PRBC's

• 11 units Cell-Saver

• 7 units Fresh Frozen Plasma

• 12 pk. Platelets

• 11,600 cc. Crystalloid

• 1750 cc. Colloid

(Plasmanate , Hespan, 5 % Albumin)

Bullets .... dangerous ? The most important wounding characteristic of a projectile is it's Kinetic Energy !

F = m x a KE = 1/2 mv²

Ballistics

• Internal: refers to the passage of a projectile within the gun barrel

• External: refers to the forces acting on a projectile after it has left the barrel & before it contacts the target

• Terminal: refers to the amount of energy impacted to the target by a missile

Bullet Velocity

• Low - Velocity: Less than 1100 ft/sec

• • Primarily injure tissue along the Wound Tract

  • e.g. Most Handguns

• High - Velocity: Greater than 2000 ft/sec

• • Primarily injure tissue via “Cavity Formation”

  • the cavity may be 30x greater than the actual bullet

  • e.g. M-16

Patterns of Energy Dispersion

Largely determined by the Density, Elasticity, & Cohesiveness of the tissue which has been penetrated

• The High Elasticity of Lung Tissue helps to Protect it somewhat from the Damaging Effects of Temporary Cavity Formation

• Liver, Spleen, & Brain Tissue are very similar to Water in Density & have almost no Elasticity !

Alterations in Flight

• Precession : a motion continuously at right angles to the plane of torque and angular momentum

• Yawing : the deviation of the bullet's longitudinal axis from the actual line of flight

• Tumbling : a three dimensional end-over-end alteration in the path of movement

Wound Tracts

• The Low-Velocity Pistol Bullet

• • Majority of Gunshot Wounds seen in the ED

  • Majority of handgun shootings occur within a 7 yard distance !

  • New York Police:

  • • Officers hit their Assailants 25 % of the time

    • Assailants hit Police Officers 11 % of the time

• A High-Velocity Chest Wound

• • A Large Cavitation Effect !

  • • The “Blast Effect”

• • Foreign Matter Componen

  • • Fragmentation ! A Pseudo-Shrapnel Effect ...Deadly

• Shotgun at a Close Range

• • Multiple Wound Tracts

  • Usually Minimal Exit Sites

  • The Effect of a “Sawed-off Shotgun”

  • • Allows a Wider Dispersion Pattern but at a Lower Velocity (the shorter barrel promotes discharge of unburned gunpowder and gas from the contained environment out into the air). “Close Range Weapon” !

• Buckshot at a Moderate Distance

• • At Ranges greater than 4 ft, the pellets will begin to disperse, with each pellet carrying an equal proportion of the muzzle energy

  • Range & the Number of Pellets in the load are the main determinants of the energy that each pellet has as it strikes the target !

• Birdshot at a Moderate Distance

• • a 12-guage shotgun loaded with no. 6 Birdshot has a muzzle velocity of 1,300 ft/sec.

  • When fired from a distance of 12 feet, the shot will penetrate a 4-in-thick telephone book, producing a hole with a 2.4-in. diameter and releasing more than 2,000 ft-lb of energy

  • An M-16 Rifle has a Muzzle Energy of 1,250 ft-lb

  • The Shotgun delivers much greater energy to a target at close range than does the M-16 !

Summary

• Pre-Hospital: Compression & Transfer

• A, B, C's

• The Type of Weapon !

• Application of Ballistic Principles

• Diagnostic studies

• Surgical Intervention

• Hopefully ... recovery.