Endoscopic Endonasal Removal of a Bullet Lodged in the Anterior Lower Clivus: A Case Report.

The past decade has witnessed rapid advancements in various surgical techniques for the clivus and surrounding structures. However, effective treatment of this region still poses significant challenges for neurosurgeons. The advent of endoscopic surgical procedure has reshaped skull base surgery in recent years. We present the rare case of a 67-year-old male gunshot victim who underwent endoscopic endonasal removal of a bullet lodged in the anterior lower clivus. The patient did not receive prophylactic antibiotic therapy. Based on this case, we propose that the endonasal endoscopic approach is highly advantageous for removing foreign bodies from the clivus. Furthermore, intraoperative navigation facilitates rapid lesion identification and reduces the surgical duration.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

Rare case of multiple self-inflicted gunshot wounds to the chest in Poland.

Multiple gunshot suicides are relatively rare and present significant challenges for investigators and forensic pathologists. In such cases, assessing the possibility of more than one shot being fired can be crucial in distinguishing homicide from suicide. We present a rare case of multiple self-inflicted gunshot wounds to the chest with severe injury to the heart and left lung. Both the sudden, unexpected death of the man, the unknown source of the firearm, and the number and nature of the injuries sustained seemed quite unusual. The investigation revealed that the wounds were self-inflicted at close range, and the interval between successive shots (estimated by witnesses at up to 2 min) suggests that even multiple gunshot wounds perforating the heart and lungs may not necessarily cause immediate incapacitation. Forensic investigations in such cases should be multi-faceted and include full autopsy and ballistics expertise, as well as witness testimony and medical history.

Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study.

BACKGROUND: The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting. METHODS: A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure. RESULTS: During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05). CONCLUSION: Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.

Assessment of Early and Late Management of Submental Gunshot Wounds.

Background: Management of submental gunshot wounds is becoming more common and requires complex surgical decisions. Objective: Compare outcomes of early and definitive reconstructive techniques following submental gunshot wounds. Methods: Retrospective chart review evaluated subjects who sustained a self-inflicted submental gunshot. The incidence of complications requiring unplanned operations was compared for early management techniques of skin/soft tissue, bone, and mucosal lining and definitive reconstructive techniques using Fisher's or Pearson Chi-square exact test with p ≤ 0.05 considered statistically significant. Results: The total of 27 patients were included. Early techniques included skin = primary soft tissue closure (n = 19) versus wound vacuum-assisted closure (n = 8); mandible = open reduction internal fixation (ORIF) (n = 19) versus external fixation (n = 8); and oral mucosal lining = primary mucosal closure (n = 20) versus dermal substitute (n = 7). Definitive management included ORIF (n = 10, 37%), ORIF with bone grafting (n = 8, 30%), and microvascular free-flap (n = 9, 33%). The incidence of complications requiring unplanned operation when using dermal substitutes for mucosal lining management was statistically higher than primary closure (p < 0.001); otherwise the complication rates of surgical techniques were equivalent. Conclusion: Several surgical decisions and techniques can be utilized at the time of early and definitive management of submental gunshot wounds. Only the use of dermal substitutes for mucosal lining is associated with a significantly higher rate of unplanned operation.

Gunshot wound injury to the genitourinary tract: a 4-year retrospective review at an academic level 1 trauma center.

Background: Firearm injuries increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to describe our experience with patients admitted to a level 1 trauma center with gunshot-related trauma to the genitourinary (GU) tract before and during COVID-19 pandemic. Methods: Patients sustaining gunshot-related trauma to the adrenals, kidneys, ureters, bladder, scrotum, testicles, penis, and urethra between January 1, 2018 and December 31, 2021 were identified from our institutional trauma database. Patient charts were queried to extract demographic information, management, and follow-up. Results: A total of 117 patients met inclusion criteria with 39 (33%) of GU injuries occurring pre-COVID, and 78 (67%) occurring during or post-COVID. Seventy-two (62%) presented with kidney injury. Patients injured in the pre-COVID period were more likely to participate in a follow-up visit by 2.17 times at 60 days (P=0.017), 1.98 times at 90 days (P=0.030), and 2.04 times at 1-year (P=0.014) than during COVID. Pre-COVID, 46% of patients were injured in the city's northwestern region and 54% from other areas, during COVID 24% of patients came from the northwestern region compared to 76% from other areas (P=0.029). Conclusions: Gunshot wounds (GSW) involving the GU tract increased during the COVID-19 pandemic, with renal injury most frequent. Follow-up visits declined by around half during the pandemic, primarily at 60 days, 90 days, and 1 year post-injury. The number of patients admitted with urologic injuries pre-COVID versus during COVID was significantly different depending on the patient's area of residence. More work is needed to evaluate the outcomes of traumatic GU injuries due to GSW pre- and post-pandemic.

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip.

BACKGROUND: Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. METHODS: A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. RESULTS: The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. CONCLUSIONS: This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

Predicting early complications in patients with spinal gunshot wounds: A multicenter study.

Introduction: There is a wide variation in the clinical presentation of spinal gunshot wounds ranging from isolated minor stable fractures to extremely severe injuries with catastrophic neurological damage. Research question: we aim to analyze the risk factors for early complications and impact of surgical treatment in patients with spinal gunshot wounds. Material and methods: This is a multicentre retrospective case-control study to compare patients with spinal gunshot wounds who had early complications with those who did not. The following matching criteria were used: sex (1:1), injury level (1:1) and age (±5 years). Univariate and multivariate analyses were performed using logistic regression. Results: Results: Among 387 patients, 36.9 % registered early complications, being persistent pain (n = 32; 15 %), sepsis/septic shock (n = 28; 13 %), pneumonia (n = 27; 13 %) and neurogenic bladder (n = 27; 12 %) the most frequently reported. After case-control matched analysis, we obtained 133 patients who suffered early complications (cases) and 133 patients who did not as control group, not differing significantly in sex (p = 1000), age (p = 0,535) and injury level (p = 1000), while the 35 % of complications group required surgical treatment versus 15 % of the non-complication group (p < 0.001). On multivariable analysis, significant predictors of complications were surgical treatment for spinal injury (OR = 3.50, 95 % CI = 1.68-7.30), dirty wound (3.32, 1.50-7.34), GCS ≤8 (3.56, 1.17-10.79), hemodynamic instability (2.29, 1.07-4.88), and multiple bullets (1.97, 1.05-3.67). Discussion and conclusion: Spinal gunshot wounds are associated with a high risk of early complications, especially when spinal surgery is required, and among patients with dirty wound, low level of consciousness, hemodynamic instability, and multiple bullets.

Epidemiologic analysis and mortality outcome of firearm injuries in French Guiana (2016-2019).

BACKGROUND: French Guiana (FG) is a French territory located in South America with the highest rate of armed assaults. FG presents a poorly developed road system and a young and precarious population that makes the geographical and socio-demographic characteristics specific. No data concerning the firearm injury management are available in this country. Studying thesis trauma could permit to improve the management of victims. The objective of this study is to investigate the epidemiology of firearm injuries in FG, to define characteristics of the victims, and to assess factors associated with death. These identified factors could enable target primary prevention and intensification of medical management. METHODS: From January 2016 to December 2019, we conducted a retrospective study at the Cayenne General Hospital (CGH), including all patients admitted for firearm injuries in the emergency department, the medical emergency and resuscitation service, and the forensic service. A bivariate analysis was performed to assess relevant clinical data that were entered into a logistic regression model to assess factors associated with death. RESULTS: A total of 871 files were analyzed concerning 340 patients included after cross-checking. Victims were mainly males (90%) and young (30 ± 11 years old). The injury occurred mainly at night (60%), in a context of assaults (83%) and with long-barreled guns (82%). Among the 290 patients managed at the CGH, 60% were hospitalized including 12% that were in the intensive care unit, 41% that required surgical treatment, and 7% that died in hospital. The overall average length of stay was 10 ± 18 days. Overall mortality (n = 71, 21%) is statistically associated with male gender (p = 0.007) and suicide context (p < 0.001). In multivariate analysis, the sites of wounds (head and neck, thorax; p < 0.001) as well as induced organ injuries (neurological, respiratory, and vascular; p < 0.005) were independent factors associated to mortality. CONCLUSIONS: This work underlines the high incidence of ballistic trauma in FG. This mainly involves a young and male population linked to the use of long arms and assaults. Despite the geographical difficulties of the territory and the technical platform deficits (no neurosurgery, no cardiothoracic surgery, no interventional radiology), the mortality is comparable to other studies, but remains more than twice as high as in mainland France. Finally, despite a change in legislation restricting access to firearms, our results show that gunshot firearm injuries remain a major public health concern requiring greater political actions.

Management of gunshot wounds near the elbow: experiences at a high-volume level I trauma center.

BACKGROUND: Gunshot-related fractures near the elbow are challenging, and available data to guide the practitioner are lacking. This report analyzes injury patterns and treatment strategies in a case series from a high-volume urban trauma center. METHODS: All periarticular gunshot fractures near the elbow treated at a level 1 trauma center from 2014 to 2018 were retrospectively reviewed. Fracture location, patient demographics, concomitant injuries, treatment modalities, and complications were analyzed. RESULTS: Twenty-four patients were identified. All patients received prophylactic antibiotics upon admission and underwent urgent surgical debridement. Open reduction and internal fixation (ORIF) was performed with initial debridement in 22 of 24 patients. Seven patients sustained distal humerus fractures, 10 patients sustained isolated proximal ulna or proximal radius fractures, and seven had combined fracture patterns. Eleven patients presented with nerve palsy, and two had transected nerves. Two patients had vascular injury requiring repair. One patient required a temporary elbow-spanning external fixator and underwent staged debridement followed by ORIF. One patient with a grade IIIC fracture developed a deep infection that precluded ORIF. One patient required revision ORIF due to fracture displacement. CONCLUSIONS: This investigation reports on management of ballistic fractures near the elbow at a busy urban level I trauma center. Our management centered on rapid debridement, early definitive fixation, and intravenous antibiotic administration. We report on associated neurovascular injury, bone loss, and other challenges in this patient population. Level of evidence: IV.

Incidence and management of traumatic vertebral artery injuries: wartime experience in Ukraine.

OBJECTIVE: Modern combat-related vertebral artery (VA) injuries are increasingly being diagnosed, but the management of such injuries remains controversial. The authors report the frequency and characteristics of combat-related penetrating VA injuries and the indications for endovascular treatment, as well as analyze their treatment outcomes. METHODS: A 1-year prospective study was completed at a civilian medical center in Dnipro, Ukraine, in all patients with VA injuries sustained during the Russian invasion in the 1st year of war. The authors evaluated the location, type, and severity of the VA injuries and concomitant injuries, as well as the type of intervention and outcomes at 1 month. RESULTS: In total, 279 wounded patients underwent cerebral angiography and 30 (10.8%) patients had VA injuries. All patients were male. There were 28 soldiers and 2 civilians with a mean age of 37.5 years. Four (13.3%) patients had Bissl grade I injuries, 4 (13.3%) had grade II injuries, 4 (13.3%) had grade III injuries (pseudoaneurysm), and 18 (60.0%) had grade IV injuries (occlusion). Four (13.3%) patients underwent emergency open surgical intervention. Fourteen (46.7%) patients underwent endovascular intervention. There was a significant relationship between the anatomical level of the VA injury and surgical intervention (p < 0.05). Endovascular intervention was correlated with the severity of vascular injury to the VA, with 12.5% of the patients receiving intervention for grade I and II lesions and 59.1% receiving intervention for grade III and IV lesions (p < 0.05). The overall mortality in the study group was 6.7% (n = 2), and both died of ischemic complications. CONCLUSIONS: In modern armed conflicts, VA injuries are much more common than reported for previous wars. With the available modern endovascular technology, cerebral angiography is warranted for suspected VA injury and allows for both the diagnosis and treatment of these injuries. Whether endovascular intervention is performed depends on the level and severity of VA injury, severity of concomitant injuries, and presence of collateral circulation.

Audiologic Consequences of Gunshot Wounds to the Temporal Bone Show No Relation to Concomitant Neurologic or Vascular Injuries.

OBJECTIVES: To evaluate audiologic consequences of gunshot wounds (GSWs) to the temporal bone (TB), and to correlate hearing outcomes with neurologic and vascular injuries adjacent to the temporal bone. STUDY DESIGN: Retrospective case series. SETTING: University-based level-one trauma center. METHODS: Retrospective review of 35 patients surviving TB ballistic injury, 2012 to 2021. Main outcomes were audiologic results. Demographics, concomitant injuries, CT, and interventions were reviewed. RESULTS: Mean age was 30.7 years; 80% male. Seventeen patients (48.6%) underwent audiologic testing. Mean pure tone average (PTA) was 75 ± 35 dB, bone line average 41 ± 26 dB, and speech discrimination score (SDS) 60 ± 43%. Nineteen (54.3%) demonstrated facial nerve injury (FNI), who were more likely to show SNHL especially anacusis, though their mean PTA and SDS were not statistically different from those without (P = .30 and .47, respectively). Radiographic review of those with sensorineural loss (SNHL, 6/17) revealed otic capsule-disrupting fracture (n = 2), pneumolabyrinth (n = 2), intracranial hemorrhage (n = 3). Those with mixed loss (6/17) showed otic capsule-sparing fracture (n = 6), EAC injury (n = 5), ossicular discontinuity (n = 2), and intracranial hemorrhage (n = 4). Two with mastoid tip fractures alone had normal audiograms. Audiometric outcomes were not predicted by concomitant CSF leak, spinal injuries, vascular injuries, cranial neuropathies, or traumatic brain injury. CONCLUSIONS: All patterns of hearing loss-conductive, sensorineural, mixed and normal-may be seen following TB ballistic injuries. Trauma severe enough to disrupt the facial nerve is more likely to cause anacusis. However, all should be formally evaluated, since ballistic injuries complicated by neurologic or vascular damage do not necessarily correlate with worse audiologic outcomes, while patients with minimal fractures may demonstrate losses.

Prophylactic removal of a migratory missile from the cerebral ventricles: case report.

BACKGROUND AND IMPORTANCE: Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention. CLINICAL PRESENTATION: We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube. CONCLUSION: The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

Maternal and Neonatal Outcomes of Gunshot Wounds in Pregnancy: A Systematic Review of Case Reports.

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy.

Targeting safety: Exploring trends and risk factors in pediatric head and neck BB gun injuries and hospitalization.

OBJECTIVE: To examine head and neck injuries caused by BB (Ball Bearing) guns treated in US emergency departments among children under 18 to identify trends in injury frequency over time and risk factors associated with severe injuries leading to hospital admission. METHODS: This retrospective study utilized data from the National Electronic Injury Surveillance System (NEISS), a single database, to analyze head and neck injuries caused by BB guns between 1993 and 2019. The analysis explored demographic characteristics and injury patterns, including sex, age, incidence, injury location, hospital type, and disposition. Linear regression was employed to assess trends in the yearly frequency of injuries, while univariate and multivariate binary logistic regression was used to calculate the odds ratios associated with hospitalization. RESULTS: A total of 4041 cases of pediatric head and neck injuries caused by BB guns and treated in US emergency departments were identified. Most patients were male (84 %), with the highest proportion of injuries occurring in the 10-14 age group (49.7 %). The face (35.8 %) and eye (27.4 %) were the most affected injury sites, and 7.5 % of patients required hospital admission. No significant linear trend was observed in injury frequency over the study period. However, children aged four and under had higher odds of hospitalization (OR 2.77, 95 % CI 1.61-4.75) despite a lower incidence of injuries. Injuries to the eye (OR 12.37, 95 % CI 8.31-18.43) and neck (OR 7.58, 95 % CI 4.76-12.06) were strong predictors of hospital admission. CONCLUSION: Pediatric BB gun-related head and neck injuries remain a source of emergency room visits nationally. Younger children are at increased risk of admission to the hospital. Eye and neck injuries were the strongest predictors of hospital admission. Implementing safety precautions for younger children is crucial, as injuries might be more severe in this age group.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa.

INTRODUCTION: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. MATERIALS AND METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. RESULTS: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. CONCLUSIONS: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber.

INTRODUCTION: Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS: The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS: Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS: Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.

[Distribution features of gunshot residue from hunting Steyr Mannlicher AUG-Z3 carbine on targets]. / Osobennosti raspredeleniya na mishenyakh produktov vystrela iz okhotnich'ego karabina Steyr Mannlicher AUG-Z3.

OBJECTIVE: To study the morphology of distribution of shot factors on white targets made of coarse calico at different distances. MATERIAL AND METHODS: The study was conducted on 57 experimental damages of targets made of cotton fabric, caused by shots from hunting self-loading Steyr Mannlicher AUG-Z3 carbine of.223 Rem caliber. The number of experimental firings equal 19 was done by 3 shots at the distance from close range to 250 cm. The examination of shot targets was carried out using the visual, metric, stereoscopic (Leica 125M microscope) methods, in ultraviolet rays (LUMATEC SUPERLITE M Series light). RESULTS: The nature and morphology of distribution of gunshot residue on targets' surfaces made it possible to establish close range firing zones. The nature in which soot is deposited during shot under the conditions of point-blank range and in the first zone of close range (up to 8 cm) allows to establish the position of weapon's transverse plane relative to the target basing on a specific blowout of a gas-powder jet from special design of flame arrestor. The performed experimental shooting from hunting self-loading Steyr Mannlicher AUG-Z3 carbine made it possible to determine the metric and morphological characteristics of the close range firing zones: 1 zone is equal a distance up to 8 cm; 2 zone - up to 30 cm; 3 zone - up to 100 cm from muzzle of weapon. The design features of Steyr Mannlicher AUG-Z3 carbine's flame arrestor allow to identify the type of weapon according to the morphological pattern of target's damage. The complex of obtained data makes it possible to determine the firing distance with high accuracy.

The wounding potential of assault rifles: analysis of the dimensions of entrance and exit wounds and comparison with conventional handguns. A multicentric study.

The appearance of a gunshot wound (GSW) is greatly influenced by the velocity of the projectile, where high-velocity projectiles (HVPs) are defined as ballistic agents reaching a muzzle velocity of > 600 m/s fired from assault rifles. The aim of the study is to present and explain the differences in the dimensions of entrance and exit wounds between the most used handguns and assault rifles and to propose a predictor of HVP, i.e., the ratio of exit and entrance wounds (EX/ENR). The surface area of entrance and exit GSWs and the EX/ENR were calculated. 66 perforating GSWs produced by NATO FMJ 7.62 × 52 mm and 5.56 × 42 mm fired from assault rifles were assigned to the HVP, while 64 lesions produced by conventional projectiles fired from revolvers and semi-automatic pistols were assigned to the low-velocity projectile (LVP) group. The dimensions of the exit wounds of the HVP group were significantly higher when compared to the LVP group (95% CI 0.9886-2.423, p < 0.05). The HVP group showed significantly higher values for the EX/ENR when compared to the LVP group (95% CI 2.617-7.173, p < 0.05). The evaluation of the EX/ENR can be considered an adequate tool to assess the type of weapon involved and to roughly estimate the associated wounding mechanisms, which can guide both the physician in the management and treatment of the patients affected by GSW, and the forensic pathologist in crime investigation.

A case of emergency reconstructive surgery following facial destructive gunshot wounds: clinical and medico-legal assessments.

BACKGROUND: Facial gunshot wounds present a complex challenge to both medical professionals and victims with significant physical, psychological, and economic implications for those who suffer these types of injuries. Reconstructive surgery offers satisfactory aesthetic and functional outcomes, improving a patient's quality of life. In these cases, the surgical procedure may encompass additional phases beyond those initially identified based on the type of wound and the extent of tissue destruction. As a result, each case necessitates thorough evaluation to determine an appropriate strategy. Nonetheless, it is worth noting that the outcomes achieved in terms of both aesthetics and functionality in this domain have the potential to be excellent. CASE PRESENTATION: A 66-year-old man attempted suicide with a shotgun, causing severe facial injuries and fractures. He had a history of depression and was taken to the emergency department promptly. CT scans revealed brain and facial bone injuries, and he underwent surgery to control bleeding and tracheostomy. Postoperative recovery was successful. The patient's condition stabilized, and he was discharged after 10 days. Follow-up visits showed gradual healing. Despite an offer for further facial reconstruction, he declined, satisfied with the achieved results. CONCLUSIONS: The present case report is intended to support the argument that effective facial reconstruction should be considered in the medico-legal assessment. It could be beneficial to introduce a new classification system and personalized evaluation methods with careful consideration given to treatment costs (which can be very high) and expected results. Since reconstructive surgery modifies damage and impacts the long-term costs of permanent impairments, its inclusion in the decision-making process would promote improved personalized care.