Penetrating Trauma to the Extremities

Steven Issley, MDEmergency MedicineMcGill University

May 8, 2002

Outline

Ballistics

Vascular injury

Orthopedic injury

Antibiotics

Wound care

Ballistics: temporary cavity

Ballistics: energy

E =E =

1/2 mv1/2 mv22

Ballistics: energy

E =E =

1/2 mv1/2 mv22

Low velocity <2500 fps

High velocity >2500 fps

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

Ballistics: shotguns

Ballistics: knife wounds

Slash

Stab

No indirect tissue damage

Ballistics: documenting exam

Entrance / exit woundsHow many woundsLocationSize, depth, shapeInjuries: detailed neurovasc State of clothesIdentify and keep missiles

write only on base or tip to maintain rifling

DOCUMENT OBJECTIVELY!

Vascular injury: anatomy

Vascular injury: hard signs

Hemorrhage: pulsatile or exsanguinating

Expanding hematoma

Bruit

Thrill

Ischemia (“6 P’s”)

Vascular injury: soft signs

Hx of significant hemorrhage

hematoma: small, non-expanding

Neurologic deficit (non-progressive)

Proximity

Vascular Injury

Complications: hemorrhage thrombosis / emoblism aneurism / pseudoaneurism compartment syndrome

Venous injury

Vascular: investigations

???? none Frykberg ‘ 91:

No sx ’s: D/C homeProximity+ No sx ’s: obs x 24h<1% missed; no morbidity

Gonzalez ‘ 99: Proximity, no hard signs24h obs = 1% missed; no morbidity

Pressure Index: Arterial or Doppler (API, DPI) sens: 45-95% for wounds

requiring OR

Vascular: investigations

Arteriogram Sens: 98% Spec: 99% Too Sens: 4% False Pos -->

unecessary OR Expensive Thrombosis / allergic reaction

Dupplex sens: 50-60% (comp. to angio) sens: 100% (wounds req. OR) spec: 99-100%

Vascular: investigations

New Kids On The Block:

CT angio

sens: 90%

spec 100%

MRI

Soft signsAPI<0.9

Proximity

AlgorithmHard signs

Shotgun II, III*High energyDestruction

*Shotgun I*High energy

- Sx ’s- Proximity

IPA>0.9Normal exam

OR Home

Angio/US

Obs 24h±Angio

-+

+ -

Orthopedic injury: bone

Low velocity Drill Hole Divot

High Velocity complicated comminuted Fragments act as 2o missiles

Stab wounds

Orthopedic injury

Joints

Lead Toxicity

Nerves

Antibiotics: wound infection

Bacrterial innoculum

Devitalized tissue

Age of wound

Location of wound

Foreign bodies

Immune compromize

Antibiotics

Lacs and Stabs

???Sterile bullets

GSW Low energy High energy

Shotguns

GSW wound care: indications for OR

Hard signs

Progressive neuro deficit

Open fracture

Unstable fractureSignificant soft tissue

damage or necrosisCompartment syndrome

Shotgun II, III

>8h post-injury

Wound care

What What

about the about the

bullet?bullet?

Summary

ATLS

Tetanus

Indication for OR? Stable /

unstable?

Further investigations?

Wound care

Antibiotics?

Bonjour la visite!

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