Heridas atípicas producidas por proyectil de arma de fuego Reporte de caso / Atypical wounds caused by firearm projectile Case report

Resumen Las heridas por proyectil de arma de fuego se definen como los efectos que producen sobre el organismo los disparos realizados con armas cargadas de proyectiles o diversos tipos de pólvora u otros explosivos. La valoración médico legal en estos casos, en personas vivas, se realiza en la Sección Clínica Médico Forense del Departamento de Medicina Legal del Organismo de Investigación Judicial, esta incluye la historia médico legal, el examen físico, el análisis de documentos médicos aportados, pericias conexas efectuadas y revisión de bibliografía, esto para tener todos los elementos de juicio que permitan realizar un análisis objetivo y basado en la evidencia científica, y así poder responder a las interrogantes de la Autoridad Judicial. El presente artículo abarca algunos de los aspectos principales a tomar en cuenta ante hallazgos atípicos de los orificios de entrada y salida de los proyectiles, mediante la presentación y abordaje de un caso clínico.

Abstract Firearm projectile injuries are defined as the effects produced on the body by shots fired with weapons loaded with projectiles or various types of gunpowder or other explosives. The legal medical assessment in these cases, in living persons, is carried out in the Forensic Medical Clinical Section of the Department of Legal Medicine of the Organismo de Investigación Judicial, this includes the legal medical history, physical examination, analysis of medical documents provided, expert carried out and bibliography review, this to have all the elements of judgment that allow an objective analysis based on scientific evidence, and thus be able to answer the questions of the Judicial Authority. This article covers some of the main aspects to be considered when faced with atypical findings of the entry and exit holes of the projectiles, through the presentation and approach of a clinical case. Ver bases de datos

Transmediastinal gunshot wound in a pregnant patient with stable hemodynamics

Abstract Transmediastinal gunshot wounds (TGWs) may lead to life-threatening injuries of vital organs such as large vessels, the esophagus, and lungs. Although they are not commonly encountered in pregnant women, additional caution should be given to these patients. Physical examination for the diagnosis and the choice of treatment modality contain controversial points in hemodynamically stable patients, and resuscitation has excessive importance due to physiological changes in pregnancy. We present a hemodynamically stable 26-week pregnant woman brought to the emergency department for TGW. She had a 1-cm diameter of bullet entrance hole on the right anterior 4th intercostal space, 2 cm lateral to the sternum, and a 3-cm diameter exit hole on the right posterior 12th intercostal space on the midscapular line.With our conservative approach, she had an uncomplicated pregnancy period, and gave birth to a healthy baby at term.

Lesiones precordiales: reporte de dos casos / Precordial injuries: report of two cases

Las heridas precordiales son una entidad poco frecuente y desafiante en cirugía de trauma en los servicios de Emergencia. La incidencia elevada de taponamiento y trauma cardiaco, así como su alta mortalidad obliga a tomar decisiones diagnósticas y terapéuticas rápidas y precisas. Material y Métodos: se presentan los casos de dos pacientes masculinos que ingresaron al servicio de Emergencia del Hospital Roosevelt con lesiones precordiales penetrantes con trauma pericárdico y cardiaco, con diferentes manifestaciones clínicas a los que se les realizó ventana pericárdica subxifoidea diagnóstica y seguido una esternotomía media con exposición pericárdica y cardiaca como abordaje y tratamiento quirúrgico definitivo. Discusión: Es de suma importancia reconocer los amplios escenarios de presentaciones clínicas del paciente con heridas en la región precordial y mantener un alto índice de sospecha de trauma y taponamiento cardiacos en todas las lesiones precordiales penetrantes en pacientes estables e inestables para no retrasar el diagnóstico y tratamiento quirúrgico temprano y adecuado. Las lesiones asociadas y complicaciones trans y postoperatorias aumentan la mortalidad de estos pacientes (AU)

Precordial wounds are rare and challenging lesions in Trauma Services. The high incidence of cardiac trauma and the high mortality requires fast and precise diagnostic and therapeutic decisions. Case report: Two male patients who were admitted to the Roosevelt Hospital Emergency Service with penetrating precordial injuries with pericardial and cardiac trauma are presented, with different clinical manifestations, who underwent a diagnostic subxiphoid pericardial window and a median sternotomy with pericardial and cardiac exposure as a definitive surgical approach and treatment. Discussion: Is important to recognize the broad scenarios of patients with wounds in the precordial region and to maintain a high index of suspicion of cardiac trauma and tamponade in all penetrating precordial injuries inclusive in stable patients to not delay diagnosis and treatment and a proper surgical intervention. Associated injuries and perioperative complications increase the mortality of these patients

Desafios na reconstrução mandibular devido a lesões extensas ou traumatismos / Challenges in mandibular reconstruction due to extensive injuries or trauma

A perda de grande parte do osso mandibular, seja devido à necessidade de ressecção óssea ou por outros fatores como a ocorrência de traumatismos, afeta diretamente a vida dos pacientes. Mesmo com a melhoria contínua dos materiais, surgimento de novas tecnologias e técnicas cirúrgicas, o tratamento dessas grandes lesões e perdas ósseas permanece como grande desafio ao cirurgião. Nesse sentido, o objetivo do presente trabalho foi relatar dois casos clínicos de pacientes, sendo um de fibroma ossificante central de mandíbula que foi submetido à ressecção mandibular e tratado através da colocação de uma placa de reconstrução do sistema 2.4 mm. O segundo caso envolveu perda de substancia devido a paciente ter sido vitima de ferimento por arma de fogo (FAF), evoluindo com fratura do sistema de fixação colocado na primeira cirurgia. Em segundo momento cirúrgico a paciente foi submetida à reconstrução óssea do defeito, associado à colocação de nova fixação. Deste modo, podemos afirmar que os procedimentos reconstrutivos são importantes instrumentos para tratamento dos pacientes.

The loss of much of the mandibular bone, is due to the need for bone resection or by other factors such as the occurrence of injuries, directly affects the lives of patients. Even with the continuous improvement of materials, development of new technologies and surgical techniques, treatment of these large lesions and bone loss is still a major challenge for the surgeon. In this sense, the objective of this study was to report two clinical cases of patients, a central ossifying fibroma of the mandible who underwent mandibular resection and treated by placement of a reconstruction plate system 2.4mm. The second case involved loss of substance because the patient has been the victim of injury by firearms (FAF), evolving with fracture fixation system placed in the first surgery. In the second surgical time the patient underwent bone reconstruction of the defect associated with the placement of new fixation. Thus, we can say that reconstructive procedures are important tools for treatment of patients.

Trauma penetrante mediástinico por bala / Transmediastinal gunshot wound treated conservatively

Los pacientes con heridas de mediastino son sometidos en un alto porcentaje a intervenciones quirúrgicas con una alta mortalidad. Pueden agruparse en aquellos que requieren cirugía o en aquellos que serán evaluados y mantenidos en observación. El 50 por ciento de los heridos por bala en el mediastino sufrirá intervención de emergencia. La selección se efectúa según la condición hemodinámica de ingreso. Menos de un 10 por ciento de los pacientes estables requerirá una operación. Caso clínico: Presentamos el caso de un paciente varón de 22 años sin antecedentes mórbidos tratado en el Hospital Barros Luco Trudeau, herido por arma de fuego, hemodinámicamente estable cuyo proyectil ingresó por vía medioesternal, atravesando el esternón y alojándose en mediastino anterior, por delante del corazón y los grandes vasos, cuya evolución y estudio descartó lesiones viscerales. Se estudió con radiografía de tórax, ecocardiografía, tomografía computarizada (TC) de tórax con contraste y laboratorio de rutina. Se realizó monitorización, se inició tratamiento antibiótico de amplio espectro y analgesia. Su evolución fue satisfactoria. A 2 años de seguimiento se encuentra clínicamente normal. Los heridos en el mediastino, hemodinámicamente estables, pueden ser evaluados y seleccionados en forma segura con TC de tórax. Hay un grupo de pacientes sin lesión mayor, que evolucionan satisfactoriamente y que no requieren cirugía.

Patients with mediastinal trauma are subjected to numerous surgical procedures and have a high mortality. Fifty percent of patients will require emergency surgery and its indication depends on their hemodynamic condition on admission. Less than 10% of hemodynamically stable patients will require surgery. Case report: A 22 years old male with a transmediastinal gunshot wound. The bullet crossed the sternum and lodged in the anterior mediastinum in front of the heart and great vessels, without causing visceral lesions. A chest X ray, echocardiography, CT scan and routine laboratory were performed. The patient was treated with antimicrobials and analgesics with a satisfactory evolution. After two years of follow up, he is in good conditions.

Retrograde venous bullet embolism after thoracic gunshot / Embolia balistica venosa retrograda apos ferimento toracico por arma de fogo

Bullet embolism is a rare complication of penetrating gunshots. We present a case of a 24-year-old man with a gunshot wound in the left scapular area, with no exit wound. Abdominal X-rays and a computed tomography (CT) scan suggested that the bullet was located within the intra-abdominal topography (intrahepatic), but laparotomy revealed no intra-abdominal injuries. After surgery, a sequential CT scan showed that the bullet had migrated to the right internal iliac vein (IIV). Venography confirmed the diagnosis of right IIV embolism and the decision was taken to attempt snare retrieval of the bullet, which was unsuccessful. It was therefore decided to leave the missile impacted inside the right IIV and the patient was put on oral anticoagulation. The patient recovered and was event free at 6 months' follow up.

Embolia balística é uma complicação rara de ferimentos por arma de fogo. Apresentamos um caso de um homem de 24 anos, vítima de um ferimento por arma de fogo em hemitórax posterior esquerdo (região escapular), sem orifício de saída. Radiografias e tomografia computadorizada do abdome evidenciaram um projétil em topografia intra-abdominal (intra-hepática); no entanto, a laparotomia exploradora demonstrou ausência de lesões intra-abdominais. Após a cirurgia, novo exame tomográfico revelou a migração da bala para a região da veia ilíaca interna (VII) direita. Realizada uma flebografia, esta confirmou a migração do projétil para a VII direita; tentou-se retirar o projétil durante o procedimento, sem sucesso. Optou-se, então, por deixá-la impactada na VII direita e manter o paciente em anticoagulação oral. O paciente evoluiu sem intercorrências até o sexto mês de seguimento.

Eventos adversos en la identificación del golpe de mina de hoffman en heridas por proyectil de arma de fuego / Adverse events in identifying hoffman´s star-like pattern in gunshot wounds

Introducción: Las heridas producidas por proyectil de arma de fuego con la boca del cañón apoyada contra la piel subyacente a una tabla ósea conforman una lesión estrellada, de bordes irregulares. Su análisis incorrecto predispone al error en la identificación del orificio de entrada. Objetivos: Remarcar la necesidad de educación continua en medicina legal en la currícula médica. Material y Método: Evaluación anónima realizada a 28 médicos con menos de 5 años de graduado. Cada una consta de siete (7) fotografías con lesiones por proyectil de arma de fuego, de las cuales dos contenían explícitamente el signo de Hoffman, y preguntas cerradas sobre los mismos.Resultados: De los 196 ítems de la serie, fueron correctamente identificados 125 (63,77%) respecto si se trata o no de un orificio de entrada. De los 56 ítems en los que se encontraba el signo de Hoffman, fueron correctamente identificados sólo 26 (46%) de los casos (Gráfico 2). Los restantes 30 casos, en los que no fue identificado el signo, fueron catalogados erróneamente como orificios de salida. Conclusiones: El golpe de mina de Hoffman se caracteriza por una lesión estrellada, irregular, con bordes dentados, producto del reflejo en una superficie ósea plana subyacente de los gases producidos por la deflagración de la pólvora. Debido a su morfología, es posible que remedre a los orificios de salida.

Introduction: Wounds produced by a firearm bullet with the muzzle of the gun pressed against the body where the skin is supported by underlying bone result in a star like or stellate lesion, with irregular borders. Their incorrect analysis leads to awrong identification of the entrance wound.Objectives: To highlight the importance of continuing educationin legal medicine included in the medical curriculum. Material and Method: Anonymous evaluation carried out with 28 doctors graduated less than 5 years ago. Each of them has seven (7) photographs showing gunshot wounds, of which two explicity showed the stellate pattern, and closed questions on them.Results: Out of the 196 items of the series, 125 (63.77%) were correctly identified whether or not it was an entrance wound. Out of the 56 items showing the stellate pattern, only 26 (46%) of the cases were correctly identified (Graphic 2). The remaining 30cases, in which the star like pattern was not identified, were wrongly listed as exit wounds. Conclusions: The stellate pattern is characterized by an irregular, star like lesion, with serrated edges, as a result of the gases produced by the deflagration of the gunpowder reflecting on the underlying bone surface. Dueto its morphology,it canmimic exit wounds.

Trauma vascular na população pediátrica / Vascular trauma in the pediatric population

CONTEXTO: O trauma vascular na população pediátrica apresenta-se como um desafio único, frente à sua incidência relativamente baixa, mesmo em centros médicos de referência. Devido à fragilidade dos tecidos, ao reduzido tamanho dos vasos e à sua baixa incidência, manifesta-se com taxas significativas de morbidade e mortalidade. OBJETIVO: Descrever e analisar os casos de trauma vascular em pacientes pediátricos admitidos em hospital terciário. MÉTODOS: Por meio de estudo retrospectivo, analisaram-se os casos de trauma vascular em pacientes menores de 18 anos, admitidos de janeiro de 2000 a julho de 2010, levando-se em conta dados demográficos, mecanismos de lesão, traumas associados, tratamentos empregados e complicações. RESULTADOS: Foram estudados 242 pacientes com trauma vascular, sendo 37 (15,2%) pertencentes à população pediátrica. A média de idade foi de 12,5 anos, sendo 81% dos participantes da pesquisa do sexo masculino. Entre os mecanismos de lesão, o trauma penetrante foi o mais comum (57%), seguido do contuso (38%) e do iatrogênico (5%). Das técnicas cirúrgicas empregadas, o enxerto arterial com veia autóloga foi o procedimento mais comum (13 casos). Houve um caso de amputação primária (infrapatelar) e quatro amputações no período pós-operatório precoce (três transfemorais e uma transtársica). Dos 11 pacientes admitidos com lesão de artéria poplítea, a taxa de amputação transfemoral pós-operatória foi de 27,3%. Houve apenas um óbito devido a trauma iatrogênico em lactente hemofílico. CONCLUSÕES: O trauma vascular pediátrico envolve vários desafios técnicos, como o vasoespasmo e o calibre dos vasos. As altas taxas de amputações observadas em pacientes com lesões de artéria poplítea, apesar das tentativas de revascularização, reforçam a gravidade desse tipo de trauma.

BACKGROUND: Vascular trauma in the pediatric population is a unique challenge, mainly due to its relatively low incidence, even in high complexity medical centers. Due to the fragility of the tissues, the small size of vessels and low incidence, it manifests with significant rates of morbidity and mortality. OBJECTIVE: To describe and analyze the cases of vascular trauma in pediatric patients admitted to a tertiary hospital. METHODS: Through retrospective study we analyzed the cases of vascular trauma in patients younger than 18 years, admitted from January 2000 to July 2010, taking into account demographic data, mechanisms of injury, associated injuries, treatment techniques and complications. RESULTS: During the studied period, 242 patients were admitted with vascular trauma, 37 (15.2%) belonging to the pediatric population. The average age was 12.5 years, and 81% of the research participants were male. Related to the mechanisms of injury, penetrating trauma was the most common (57%), followed by blunt (38%) and iatrogenic (5%). Among the surgical techniques employed, arterial bypass with autologous vein was the most common (13 cases). There was a case of primary major amputation (below the knee) and four amputations in the early postoperative period (three transfemoral and one transtarsic). For the 11 patients admitted with popliteal artery injury, the rate of postoperative transfemoral amputation was 27.3%. There was only one death due to an iatrogenic trauma in a hemophilic lactant. CONCLUSIONS: Vascular trauma in pediatric patients involves several technical challenges, such as vasospasm and vessel diameter. The high rates of amputation in patients with popliteal artery injuries, despite attempts of revascularization, reinforce the seriousness of this type of trauma.

Levantamento epidemiológico de cegueira e perda do globo ocular por agressões físicas e por armas de fogo em uma instituição pública de ensino superior do Recife / Epidemiological survey of blindness and loss of eyeball by physical aggression and weapons injuries in a public institution of higher education of Recife

Introdução: A violência é um fenômeno endêmico e suas causas são multifatoriais, envolvendo aspectos biológicos, econômicos e socioculturais. Dentre os vários tipos de violência urbana, as agressões físicas e com armas vêm tomando um lugar de destaque nos serviços de saúde pelas sequelas que acarretam. O objetivo do presente estudo retrospectivo e quantitativo consistiu em determinar a prevalência da perda do globo ocular devido a agressões físicas e armas a partir de prontuários de pacientes mutilados faciais da Clínica de Prótese Buco-Maxilo-Facial da Universidade Federal de Pernambuco û UFPE. Métodos: A amostra constituiu-se de 263 pacientes reabilitados com prótese ocular, dos quais 53 foram selecionados por apresentarem trauma ocular associado à violência urbana. O perfil sociodemográfico e econômico evidenciou que eram predominantemente jovens e adultos de até 49 anos (66,0%), do sexo masculino (79,2%), procedentes do Recife e sua Região Metropolitana (63,4%), com baixa escolaridade e renda individual de até dois salários mínimos. Resultados: Os casos de traumatismos por armas de fogo foram mais prevalentes (73,6%) do que por agressão física, tendo sido a rua o principal espaço social (88,4%) para a expressão da violência. Conclusão: Os autores concluem que o controle de traumatismos por causas externas dessa natureza está na dependência de uma abordagem socioecológica da saúde.

Introduction: The violence is an endemic and multifactorial phenomenon, wich involves biological, economical and social aspects. Among the various types of urban violence, assault and use of weapons are taking a prominent place in health services because of the sequels that they lead. The aim of this retrospective study is to determine quantitatively the prevalence of loss of the eyeball due to physical assaults and to use of weapons through the medical records of mutilated facial patients attended in Maxillofacial Prosthesis Clinic at the Universidade Federal de Pernambuco (UFPE). Methods: The sample was 263 patients rehabilitated with ocular prosthesis, 53 from them were selected because they presented ocular trauma associated with urban violence. The socio-demographic and economic profile revealed that they were predominantly young people and adults up to 49 years (66.0%), males (79.2%), coming from the Metropolitan Region of Recife (63.4%), with low education level and individual income up to two minimum wages. Results: The cases of injuries caused by firearms were more prevalent (73.6%) than by physical aggression, and the street was the main social place where that happened (88.4%). Conclusion: The authors conclude that the control of injuries from external causes depends on a socio-ecological approach to health.

Ureteral injuries from gunshots and shells of explosive devices

Penetrating rather than blunt trauma is the most common cause of ureteral injuries. The approach to management differs from the far more common iatrogenic injury. The purpose of this series is to report our experience in ureteral trauma management, with attention to the diagnosis, repair, and outcome of these injuries. From April 2003 to October 2009, all abdominal trauma cases received alive, reviewed for penetrating ureteric injuries A total of twenty [fifteen male, five female] penetrating ureteral injuries were evaluated. All penetrating ureteric injuries were due to [9 gunshot and 11 shells from explosive devices]. Since the patients had a clear indication for surgery, no IVU or CT scan was done preoperatively, major intra-abdominal injuries were often associated. The diagnosis of ureteric injury was made intraoperatively in 8 cases [40%] While, twelve cases [60%] were diagnosed postoperatively. Eight ureteric injuries [40%] were proximal 1/3, 4 [20%] to middle 1/3 and 8 [40%] to the distal 1/3. Management was with stenting in 2 patients, ureteroureterostomy in 8, ureteroneocystostomy in 6, and nephrectomy in 4. In this study, a delay in diagnosis was a contributory factor in morbidity related to ureteral injury, the need for second operation in already compromised patients from associated injuries, The presence of shock on admission, delayed diagnosis, and colon injuries were associated with a high complication rate. Ureteral injuries must be considered early during the evaluation of penetrating abdominal injuries

Herida transfixiante cérvicotoracica en un paciente pediátrico / Transfixiante wound cervicoracic in a patient pediatric

Se presenta un niño de 8 años que sufrió una herida por arma de fuego con puerta de entrada a nivel cervical y sin orificio de salida. El proyectil se alojó en posición intraarticular en hombro izquierdo recorriendo en forma transfixiante el mediastino superior. Las lesiones produjeron un pseudoaneurisma de la arteria subclavia izquierda que fue tratado mediante la colocación de un dispositivo de clausura intraarterial con buena evolución. Comentamos su evaluación durante la urgencia, metodología diagnóstica y tratamientos realizados. Evaluamos como satisfactoria su evolución y ponemos a consideración un novedoso tratamiento que nos ha permitido un manejo selectivo de una grave lesión arterial.(AU)

Causalgia após trauma por projétil de arma de fogo: relato de caso / Post-traumatic causalgia due to firearm projectiles: case report

Causalgia é um tipo de doença neurológica crônica pertencente à Síndrome Dolorosa Regional Complexa, normalmente associada ao trauma. A sintomatologia é caracterizada por dor espontânea em queimação, hiperalgesia, edema, instabilidade vasomotora, alteração da função motora e anormalidades autonômicas. É rara, pouco conhecida e envolve várias teorias acerca de sua fisiopatologia. São descritas neste trabalho as manifestações de paciente masculino, de 20 anos, atendido no Pronto Socorro do Hospital Risoleta Tolentino Neves, vítima de múltiplas lesões por projéteis de arma de fogo, que evoluiu com manifestações compatíveis com causalgia.

Causalgia is a kind of chronic neurological disorder which is part of the Complex Regional Pain Syndrome, usually associated to trauma. Its symptoms are severe burning pain, hyperalgesia, edema, abnormal vasomotor activity, impairment of motor function and autonomic dysfunction. It is a rare, poorly known disease, which involves various theories in regard to its physiopathology. We report, in this article, a clinical case of a 20-year-old male patient, who was treated in the Emergency Room of Risoleta Tolentino Neves Hospital, victim of multiple lesions by firearm projectiles and evolved with symptoms compatible to the clinical features of Causalgia.

Trauma transfixante: relato de caso / Transfixing traum: case report

Atualmente os traumas por arma de fogo estão cada vez mais comuns, principalmente na população com idadeprodutiva. Lesões cervicais por esse mecanismo são de grande importância por sua morbimortalidade. Suspeitardo diagnóstico e dar o suporte adequado é de extrema importância para salvar a vida do paciente. Nosso objetivo é descrever um caso de ferimento transfixante por PAF em região cervical, com fístula artériovenosa, que obteve um bom desfecho.

Nowadays traumas caused by firearms are more and more common, particularly among working age population. Cervical lesions caused by this mechanism are ofgreat importance for its morbimortality. Distrusting the diagnosis and giving the appropriate support is of the utmost importance to save the life of the patient. Our objective is to describe a case of transfixing wound by PAF in a cervical region, with arteriovenous fistula, which had a good outcome.

Manejo conservador de lesión hepática por arma de fuego: presentación de un caso / Conservative management of hepatic lesion by fire arm: presentation of a case

Se presenta un caso de trauma abdominal penetrante por arma de fuego que lesiona hígado y en el cual se mantuvo actitud conservadora gracias al empleo de técnicas diagnósticas videolaparoscópicas. Se exponen los datos clínicos del paciente, su manejo, donde es llamativo que no hubo necesidad de intervenir quirúrgicamente, así como su posterior evolución. Se revisan los elementos fundamentales a tener en cuenta cuando el cirujano actuante decide seguir conducta conservadora

We present a case of abdominal penetrant trauma by fire arm, harming liver, in which a conservative attitude was maintained thanks to the employment of videolaparoscopic diagnostic techniques. We expose the patient's clinical data, the trauma management, being important to say there was not necessity of surgical intervention, and also the posterior evolution. We reviewed the main elements taken into account when the surgeon decides to follow a conservative behaviour.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.

Caracterización de fracturas abiertas de fémur Hospital Pérez de León: período 2000-2006 / Characterization of fractures open of femur Hospital Pérez de León: period 2000-2006

Se realiza un estudio retrospectivo de 59 historias clínicas correspondientes al total de pacietes hospitalizados con el diagnóstico de fractura abierta de fémur en el Hospital de Emergencia Pérez de León de Petare, en el período 2000-2006; con la finalidad de caracterizar dichas fracturas con respecto a diversas variables: incidencia (año 2006: 27.12 por ciento), sexo (masculino: 94.92 por ciento), edad (20-25 años: 35.59 por ciento), localización (tercio medio: 25.42 por ciento), mecanismo de lesión (arma de fuego: 91.53 por ciento), clasificación (Grado III a: 55.93 por ciento), trazo de fractura (conminuta: 88.14 por ciento) tratamiento (quirúrgico: 86.44 por ciento).

Heridas de bala en colon y recto. Experiencia en el Servicio de Emergencia de un Hospital General de Agudos en el Gran Buenos Aires / Gunshot wounds in colon and rectum. Experience in the Emergency Service of an Acute General Hospital in Gran Buenos Aires

Introducción: La incidencia y la gravedad de las lesiones por proyectiles de armas de fuego (PAF) aumentaron considerablemente en los últimos años, con mayor impacto en las edades tempranas, siendo esta tendencia mundial. Pacientes y métodos: Estudiar los pacientes ingresados en nuestro hospital por PAF y compararlo con otras series. Diseño: retrospectivo. Población: 598 pacientes entre junio 1997 y junio 2004. Se considera: incidencia, sexo, edad, áreas de impacto, con un análisis especial en las lesiones de colón y recto, estudiando: topografía de las lesiones, asociación con otros órganos, estrategia terapéutica y morbimortalidad. Resultados: Total de pacientes 598, masculino: 513 (85,7 por ciento), femenino: 85 (14,3 por ciento). Edad promedio: 32,56 años, rango de 10 a 85. Areas de impacto: tronco 168 (28,08 por ciento), miembros: superiores 8 (14,04 por ciento), inferiores 334 (55,85 por ciento), compromiso colorrectal 29 (20 por ciento de las abdominales). Topografia: ciego 2 pacientes (6,8 por ciento), colon ascendente 1 (3,4 por ciento), ángulo hepático 2 (6,8 por ciento), transverso 4 (13,7 por ciento), ángulo esplénico 1 (3,4 por ciento), descendente 6 (20,6 por ciento), sigmoides 6 (20,6 por ciento) y recto 7 (24 por ciento). Órganos asociados: mesenterio e intestino delgado 8 pacientes, epiplón mayor 6, estómago 4, hígado 3, bazo 2, páncreas 2, vena ilíaca 3; arteria ilíaca 2, arteria aorta 1. Tratamientos realizados: cecostomía 2 pacientes, colostomía sobre varilla 9, exteriorización y cierre primario 4, operación tipo Lahey 4, operación tipo Hartmann 7, resección y anastomosis 3 y drenaje presacro 4 pacientes. Complicaciones: absceso de pared 8 pacientes (27,5 por ciento), peritonitis 4 (13,7 por ciento), evisceración 2 (6,8 por ciento), hemorragia 2 (6,8 por ciento), metabólicos 4 (13,7 por ciento). Mortalidad 2 pacientes. Discusión: en nuestra serie, 1 de cada 1200 admisiones en el servicio de emergencia correspondió a PAF, la mayoría, 69,89

Civilian cranial gunshot wounds: a Jamaican experience

Gunshot injuries are an escalating social and medical dilemma in many Western and some developing countries. Of 40 patients arriving at the University Hospital of the West Indies (UHWI), Jamaica, from 1993 to 1998, with gunshot wounds of the head, 30 were admitted. Six of those admitted died within 24 hours, five with poor Glasgow Coma scores. Ten patients had surgery, two of whom died. Six complications occurred: two patients each developed an infection, cerebrospinal fluid fistula or seizures. All patients were victims of an assault and all had intracranial penetration, the most common sites of which were facial and frontal. Median hospital stay was eleven days. The Glasgow Coma Score on admission was a good prognostic indicator. Fourteen patients had associated injuries, four of which were in the neck. Surgery was considered inappropriate for moribund patients and those with inaccessible bone and bullet fragments. Young males were the most common victims of this devastating form of assault