Unusual trajectory of a bullet from the shoulder to the brain: an emergency department perspective on finding a missing bullet.

Terminal ballistics continues to struggle with bullet trajectory reconstruction and interpretation. This is a case of a young man presented with a very unusual trajectory of a bullet from the left shoulder to the brain parenchyma. The single wound and altered mentation prompted a CT head and neck scan, which revealed a retained bullet in the brain parenchyma, traversing from the left shoulder, across the neck and into the brain without causing significant damage to vital organs. We managed the patient conservatively. Emergency physicians dealing with gunshot injuries should thoroughly search for the bullet in cases where only a single wound is present and the bullet is missing, and they should have a basic understanding of the ballistics to understand the mechanism and injury pattern sustained by the bullet. This atypical ballistic trajectory scenario emphasises the need to exercise vigilance in accurately predicting the trajectory when the ballistic route is unknown.

Navigating the complexity of spinal cord injuries with retained foreign bodies and the diagnostic challenge of lead toxicity-a case reportaaa.

INTRODUCTION: Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population. CASE PRESENTATION: This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively. DISCUSSION: Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions.

Vesicocutaneous fistula at site of closed suprapubic tube tract as the first presenting sign of giant bladder stone.

Bladder stones represent approximately 5% of all cases of urolithiasis and are typically identified and managed long before causing irreversible renal injury. We present a case of a man in his 40s with a prior history of a gunshot wound to the abdomen who presented with leakage from a previously healed suprapubic tube tract and was found to have a giant bladder stone with a resulting renal injury. He subsequently underwent a combined open cystolithotomy and vesicocutaneous fistulotomy during his hospitalisation, which helped to improve his renal function. In addition to there being few reported cases of bladder stones >10 cm, this represents the first report in the literature of an associated decompressive 'pop-off' mechanism through a fistulised tract.

Pancreaticoureteric fistula following penetrating abdominal trauma: A Case Report.

Pancreaticoureteric Fistula (PUF) is a very rare complication secondary to penetrating abdominal trauma involving the ureter and pancreatic parenchyma. Pancreatic injuries carry h igh morbidity due to the involvem ent of surrounding structures and are d ifficult to diagnose due to thei r retroperitoneal location. A case of a patient is reported at Civil Hospital, Hyderabad who presented with a history of firearm injury and missed pancreatic duct involvement on initial exploration that eventually led to the development of Pan creaticoureteric Fistula. He was managed v ia p erc ut aneous nep hrostomy ( PCN ) for the right ureteric injury and pancreatic duct (PD) stenting was done for distal main pancreatic duct injury (MPD).

Utilizing Video-Assisted Retroperitoneal Debridement for Retroperitoneal Abscess Following Penetrating Trauma.

Retroperitoneal abscess as a sequela of penetrating trauma can pose a difficult clinical scenario for surgeons and literature to inform decision making is sparse. It is logical to follow a "step-up" approach applied to other etiologies of infected retroperitoneal fluid collections, such as infected pancreatic necrosis and perinephric abscess. Video-assisted retroperitoneal debridement (VARD) is a well-established approach in infected pancreatic necrosis when surgical debridement is warranted. Minimally invasive retroperitoneal approaches have emerged in a broadening range of etiologies and specialties. We describe our experience utilizing VARDs in two patients that developed retroperitoneal abscesses following gunshot injuries to bowel and proximal urinary system. Both failed a conservative approach including antibiotic and percutaneous drains. Rapid improvement and subsequent discharge were observed within days of VARD procedure. We believe VARD to be a viable approach to post-trauma retroperitoneal abscesses when surgical drainage is indicated, and anatomy is favorable.

Prognostic Significance of Multifactorial Analysis in Complex Cervical Aero-Digestive Trauma Cases.

Background and Objectives: In the context of complex aerodigestive cervical traumas, the prognosis and outcome heavily depend on risk factors, particularly injuries to the larynx, trachea, major digestive tissues, cervical vertebrae, and vascular structures. With the increasing prevalence of trauma as a public health concern, there is a pressing need for epidemiological research and the implementation of preventative measures. The purpose of this research is to establish the profile of the predictable impact factors that determine the prognosis of patients with complex cervical trauma. Methods and Methods: The study group consisted of 106 patients with complex cervical trauma pathology developed by various mechanisms such as car accidents, home-related accidents, aggression, gunshot wounds, and self-inflicted attempts, resulting in hospitalization in the E.N.T. Clinic at "St. Spiridon" Iași Hospital, from 2012 to 2016; medical records were the source of the collected data. Results: Hemodynamic instability upon admission associated with age, muscle and laryngeal injuries, and anemia were identified as negative prognostic factors. Additionally, the utilization of imaging-based paraclinical investigations for diagnosing traumatic lesions emerged as a positive prognostic factor in managing this pathology. The management of penetrating cervical trauma remains a subject of debate, with some advocating for surgical exploration beyond the platysma layer in all cases, while others argue for a more selective conservative approach due to a high rate of negative explorations. Conclusions: The statistical evaluation of epidemiological, clinical, lesion, paraclinical, and therapeutic parameters is needed to establish predictable risk factors in the prognosis of complex aerodigestive cervical trauma.

Management of penetrating cardiac injury and tricuspid regurgitation with extracorporeal-membrane oxygenation (ECMO): a case report.

BACKGROUND: Gunshot wounds (GSW) to the heart are lethal, and most patients die before they arrive to the hospital. Survival decreases with number of cardiac chambers involved. We report a case of a 17-year-old male who survived a GSW injury involving two cardiac chambers with acute severe tricuspid regurgitation (TR) who subsequently developed cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO) support. CASE PRESENTATION: A 17-year-old male sustained a single gunshot wound to the left chest, resulting in pericardial tamponade and right hemothorax. Emergency sternotomy revealed injury to the right ventricle and inferior cavoatrial junction with the adjacent pericardium contributing to a right hemothorax. The cardiac injuries were repaired primarily. Tricuspid regurgitation was confirmed immediately postoperatively. Five days after presentation, the patient developed cardiogenic shock secondary to TR requiring emergent stabilization with ECMO. He subsequently underwent successful tricuspid valve replacement. CONCLUSIONS: This is the first report to our knowledge of successful ECMO support of severe TR due to gunshot injury to the heart.

Patterns of firearm related injury in the elderly: A single institution analysis.

BACKGROUND: Firearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic. METHODS: A retrospective review of the trauma registry at a large Level I center was performed from 2016-2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18-64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition. RESULTS: 23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7-93.1] compared to 63.7 [IQR 33.2-83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in "at risk" or "distressed" communities. CONCLUSION: FRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center.

INTRODUCTION: Thigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury. METHODS: A trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent). RESULTS: There were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9-28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232-5339] and reached a peak of 5271 [3013-13,266]. The median time from admission to diagnosis was 6.8 [0-236.9] hours. The median time from admission to the operating room was 8.2 [0.6-236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4-15]. The median hospital length of stay was 16.5 days [13.25-38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52-$21,893.13]. No patients required readmission within 60 days. There were no mortalities. CONCLUSION: TCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

Antibiotic prophylaxis following low-velocity gunshot fractures: an updated review.

PURPOSE: Low-velocity gunshot fractures (LVGFs) are a common type of gunshot-induced trauma with the potential for complications such as infection and osteomyelitis. The effectiveness of antibiotic therapy in LVGFs remains uncertain, leading to ongoing debate about the appropriate treatment. In this review, we evaluate recent updates on the current understanding of antibiotic therapy in LVGFs, how previous studies have investigated the use of antibiotics in LVGFs, and the current state of institutional policies and protocols for treating LVGFs with antibiotics. METHODS: We conducted a review of PubMed, Embase, and Web of Science databases to identify studies that investigated the use of antibiotics in LVGFs after the last review in 2013. Due to the lack of quantitative clinical trial studies, we employed a narrative synthesis approach to analyze and present the findings from the included primary studies. We categorized the outcomes based on the anatomical location of the LVGFs. RESULTS: After evaluating 67 publications with the necessary qualifications out of 578 abstracts, 17 articles were included. The sample size of the studies ranged from 22 to 252 patients. The antibiotics used in the studies varied, and the follow-up period ranged from three months to ten years. The included studies investigated the use of antibiotics in treating LVGFs at various anatomic locations, including the humerus, forearm, hand and wrist, hip, femur, tibia, and foot and ankle. CONCLUSION: Our study provides updated evidence for the use of antibiotics in LVGFs and highlights the need for further research to establish evidence-based guidelines. We also highlight the lack of institutional policies for treating LVGFs and the heterogeneity in treatments among institutions with established protocols. A single-dose antibiotic approach could be cost-effective for patients with non-operatively treated LVGFs. We suggest that a national or international registry for gunshot injuries, antibiotics, and infections could serve as a valuable resource for collecting and analyzing data related to these important healthcare issues.

Infectious profiles in civilian gunshot associated long bone fractures.

PURPOSE: There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates. METHODS: We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection. RESULTS: 347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05). CONCLUSION: This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.

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.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017.

BACKGROUND: Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. METHODS: For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. RESULTS: We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. CONCLUSIONS: Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. TRIAL REGISTRATION: Retrospective analysis without intervention.

Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study.

BACKGROUND: Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. METHODS: Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. RESULTS: Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. CONCLUSION: The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

Close-Range Fire Inflicting Behind Armor Blunt Trauma: Case-Series and Implications for Battlefield Care.

Behind armor blunt trauma (BABT) is a non-penetrating injury caused by energy transfer and rapid deformation of protective body armor. Although modern military body armor is designed to prevent penetrating trunk injuries, high-energy projectiles can produce a significant energy transfer to tissues behind the armor and inflict injuries such as fractures or organ contusions. However, knowledge of BABT is limited to biomechanical and cadaver modeling studies and rare case reports. We report two cases of BABT resulting from close-range fire and discuss the potential implications for triaging patients with BABT in battlefield scenarios. In the first case, a 19-year-old male soldier sustained a single close-range 5.56-mm assault rifle gunshot to his chest body armor. The soldier initially reported mild pain in the parasternal region and assessment revealed a 4 cm × 3 cm skin abrasion. Following emergency department evaluation, the soldier was diagnosed with a non-displaced transverse fracture of the sternal body. In the second case, a 20-year-old male sustained five machine gun bullets (7.62 mm) to his body armor. Computed tomography of the chest revealed pulmonary contusions in the right lower and middle lobes. Both soldiers achieved full recovery and returned to combat duty within several weeks. These cases highlight the potential risks of energy transfer from high-velocity projectiles impacting body armor and the need for frontline providers to be aware of the risk of underlying blunt injuries. Further reporting of clinical cases and modeling studies using high-velocity projectiles could inform recommendations for triaging, evacuating, and assessing individuals with BABT.

Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center.

BACKGROUND: Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS: In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS: The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS: Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

A predictive model of motor deficit in civilian ballistic lumbosacral spine injuries.

BACKGROUND CONTEXT: Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers. PURPOSE: Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology. STUDY DESIGN: Retrospective chart review. PATIENT SAMPLE: One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2. OUTCOMES MEASURES: Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale. METHODS: IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve. RESULTS: Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit. CONCLUSIONS: Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present.

Association of Cerebrovascular Injury and Secondary Vascular Insult With Poor Outcomes After Gunshot Wound to the Head in a Large Civilian Population.

BACKGROUND AND OBJECTIVES: Cerebrovascular injury (CVI) after civilian gunshot wound to the head (GSWH) likely contributes to poor outcomes, but little supporting evidence exists. The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or rehemorrhage) were associated with poor outcomes in a large civilian population. METHODS: This was a single-institution, retrospective cohort study on patients admitted between January 2014 and July 2022 at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used. RESULTS: A total of 512 civilian patients presented with GSWH, and a cohort of 172 (33.5%) met inclusion criteria, with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), and that of secondary vascular insult was 32.2% (28/172 patients). Bifrontal trajectories (adjusted odds ratio [aOR] 13.11; 95% CI 2.45-70.25; P = .003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; P < .001) were associated with increased odds of resultant CVI. Patients with CVI suffered higher rate of mortality (34% vs 20%; odds ratio [OR] 2.1; CI 0.78-5.85; P = .015) and were less likely to achieve a good functional outcome with a Glasgow Outcome Score of 4-5 (34% vs 68%; OR 0.24; CI 0.1-0.6; P = .004) at follow-up. Furthermore, patients with CVI and resultant secondary vascular insult had even worse functional outcomes (Glasgow Outcome Score 4-5, 16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, P = .001). CONCLUSION: Intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying CVI may prove to be critical to improve outcomes by reducing stroke and rehemorrhage incidence.

32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

Hospital Course and Complications of Subaxial Cervical Trauma Patients With Tetraplegia or Paraplegia: A Case Series and Literature Review.

STUDY DESIGN: A single-institution, retrospective cohort study. OBJECTIVE: The objective was to present demographic characteristics, mechanism of injuries, lengths of stay, intensive care unit (ICU) days, discharge locations, and causes of 90-day readmission for patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia. SUMMARY OF BACKGROUND DATA: Spinal cord injuries resulting in paraplegia or tetraplegia are rare injuries with debilitating outcomes. Numerous advances have occurred in caring for these patients, but patients still experience multiple complications. The severity of these injuries and numerous complications result in prolonged hospital stays and the need for extensive rehabilitation. METHODS: Twelve patients with subaxial spinal cord injury resulting in paraplegia or tetraplegia from a level 1 adult trauma center were reviewed. The primary outcomes included hospital length of stay, ICU days, intrahospital complications, 90-day readmission rates, and discharge location. We reviewed the literature for these outcomes in spinal cord injuries. RESULTS: For patients with subaxial spinal cord injuries resulting in paraplegia and tetraplegia, the average age was 36.0 years, and most were male [91.7% (11/12)]. The most common mechanism of injury was gunshot wounds[41.7% (5/12)]. Patients spent an average of 46.3 days in the hospital and 30.7 days in the ICU. Respiratory complications were the most common (9 patients). Fifty percent of patients (6/12) were discharged to the inpatient spinal cord rehab center, and 16.7% (2/12) expired while in the hospital. Two patients (20.0%) were readmitted within 90 days of discharge. CONCLUSIONS: Most patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia were young males with high-energy traumas. Many patients had intrahospital complications, and most were discharged to the hospital spinal rehab center. These findings likely stem from the severity of paraplegia and tetraplegia injuries and the need for rehabilitation.