Penetrating Trauma to the Extremities

1
Penetrating Trauma to the Extremities

• Steven Issley, MD
• Emergency Medicine
• McGill University
• May 8, 2002

2
Outline

• Ballistics
• Vascular injury
• Orthopedic injury
• Antibiotics
• Wound care

3
Ballistics temporary cavity
4
Ballistics energy

• E
• 1/2 mv2

5
Ballistics energy

• E
• 1/2 mv2
• Low velocity lt2500 fps
• High velocity gt2500 fps

6
Ballistics types of firearms

• Handguns low velocity
• 38mm 600-870 fps
• 9mm 860 fps
• 22mm 1200 fps
• Military high velocity
• M16 3250 fps
• AK47 2340 fps
• Shotguns low velocity
• 1100-1500 fps

7
Ballistics shotguns
8
Ballistics knife wounds

• Slash
• Stab
• No indirect tissue damage

9
Ballistics documenting exam

• Entrance / exit wounds
• How many wounds
• Location
• Size, depth, shape
• Injuries detailed neurovasc
• State of clothes
• Identify and keep missiles
• write only on base or tip to maintain rifling
• DOCUMENT OBJECTIVELY!

10
Vascular injury anatomy
11
Vascular injury hard signs

• Hemorrhage pulsatile or exsanguinating
• Expanding hematoma
• Bruit
• Thrill
• Ischemia (6 Ps)

12
Vascular injury soft signs

• Hx of significant hemorrhage
• hematoma small, non-expanding
• Neurologic deficit (non-progressive)
• Proximity

13
Vascular Injury

• Complications
• hemorrhage
• thrombosis / emoblism
• aneurism / pseudoaneurism
• compartment syndrome
• Venous injury

14
Vascular investigations

• ???? none
• Frykberg  91
• No sx s D/C home
• Proximity No sx s obs x 24h
• lt1 missed no morbidity
• Gonzalez  99
• Proximity, no hard signs
• 24h obs 1 missed
• no morbidity
• Pressure Index Arterial or Doppler (API, DPI)
• sens 45-95 for wounds requiring OR

15
Vascular investigations

• Arteriogram
• Sens 98
• Spec 99
• Too Sens 4 False Pos --gt unecessary OR
• Expensive
• Thrombosis / allergic reaction
• Dupplex
• sens 50-60 (comp. to angio)
• sens 100 (wounds req. OR)
• spec 99-100

16
Vascular investigations

• New Kids On The Block
• CT angio
• sens 90
• spec 100
• MRI

17
Algorithm
Hard signs Shotgun II, III High
energy Destruction
Soft signs APIlt0.9 Proximity
Shotgun I High energy
- Sx s - Proximity IPAgt0.9 Normal exam
Angio
Obs 24h
-

Angio/US

-
OR
Home
18
Orthopedic injury bone

• Low velocity
• Drill Hole
• Divot
• High Velocity
• complicated
• comminuted
• Fragments act as 2o missiles
• Stab wounds

19
Orthopedic injury

• Joints
• Lead Toxicity
• Nerves

20
Antibiotics wound infection

• Bacrterial innoculum
• Devitalized tissue
• Age of wound
• Location of wound
• Foreign bodies
• Immune compromize

21
Antibiotics

• Lacs and Stabs
• ???Sterile bullets
• GSW
• Low energy
• High energy
• Shotguns

22
GSW wound care indications for OR

• Hard signs
• Progressive neuro deficit
• Open fracture
• Unstable fracture
• Significant soft tissue damage or necrosis
• Compartment syndrome
• Shotgun II, III
• gt8h post-injury

23
Wound care

• What about the bullet?

24
Summary

• ATLS
• Tetanus
• Indication for OR? Stable / unstable?
• Further investigations?
• Wound care
• Antibiotics?
• Bonjour la visite!

25
References

• Arrillaga A, Nagy K, et al. Practice Management
  Guidelines forPenetrating Trauma to the Lower
  Extremity. EAST Trauma Practice Guidelines.
  http\\www.east.org .
• Barlett CS, Helfet DL. Ballistics and Gunshot
  Wounds  Effect on Musculoskeletal Tissues. J Am
  Acad Ortho Surgeons. 8(1)  Jan/Feb 2000.
• Dake AD, Stack LS. Penetrating Trauma to the
  Extremities Systematic Assessment and Targeted
  Management of Weapons-Related Injuries. Emergency
  Medicine Reports. March 31, 1997.
• Fesmire FM, Dalsey WC, et al. American College of
  Emergency Physicians Clinical Policy for the
  Initial Approach to Patients Presenting With
  Penetrating Extremity Trauma. Annals Emerg Med
  33(5)612-36. May 1999.
• Frykberg ER, Dennis JW. The Reliability of
  Physical Exam Vascular Injury Results at One
  Year. J Trauma. 31(4)502-11. Apr 1991.
• Gonzalez RP, Falimirski ME. Th Utility of
  Physical Penetrating Extremity Trauma. Am
  Surg. 65(8) 784-9. Aug 1999.
• Leibner EC, Jackimczyk K. Penetrating Extremity
  Trauma  The Problem of Occult Vascular Injury.
  Emergency Medicine Reports. Jan 11, 2001.
• Rathlev N. Peripheral Vascular Injuries.
  eMedicine Journal. 2(6) June 22, 2001.
• Newton E. Peripheral Vascular Injuries in
  Rosen s Emergency Medicine  Concepts and
  Clinical Practice, 5th Ed. Mosby 2002.
• http\\www.trauma.org