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BALLISTIC INJURIES

BALLISTIC INJURIES. JIKUPAL M.THOMAS. INTRODUCTION AND EPIDEMIOLOGY. Bullets or fragments Severity Wound entirely different Management Preparation in our hospital. INTRODUCTION. HOW?. – these cause wounds, Assessment Treatment.

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BALLISTIC INJURIES

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  1. BALLISTIC INJURIES JIKUPAL M.THOMAS

  2. INTRODUCTION AND EPIDEMIOLOGY • Bullets or fragments • Severity • Wound entirely different • Management • Preparation in our hospital INTRODUCTION

  3. HOW? – these cause wounds, Assessment Treatment

  4. TYPESLOW VELOCITY AND HIGH VELOCITY MISSILE WOUNDS

  5. 1.Low velocity missile wounds • From hand guns • Heavy bullets • 150-350 mps • Crushed and forced apart • Drilling a simple hole • Vital structures • Comparable to knifes • No energy transmitted • No hidden injuries

  6. 2.High velocity missile wounds • From rifles and fragments of explosives • Velocity greater than speed of sound • Impact • KE=1/2mv* • Severity -Part, Length and Energy • Energy transferred -density and stability.

  7. High-energy gunshot wound passing through the knee

  8. 1. Shock Waves Compressed Moves away-1500mps Millionth of a second Extremely high pressures Damage tissues at distance Severity lies in two:

  9. 2. Temporary Cavitation • Transfer energy • Forwards and outwards violently. • Cavity 30 to 40 times diameter of missile. • Subatmospheric pressure • Entry and exit • Collapse down- actively sucking • About 500ml totally destroyed.

  10. Dead Muscles • Plum red colour, doesn’t contract and doesn’t bleed. • Directly proportional to density • Homogenous very susceptible • Lung, resistant.

  11. Inversely proportional to elastic fibres • Skin and lung resistant. • Hits bone fragments as secondary missile • Large exit wounds

  12. Instability of the missile • Stable on impact, • Only 10-20% • Unstable, 60-70% • Fragments on impact • All energy • Liver, spleen and brain • Pulped tissue withdebris and bacteria

  13. MANAGEMENT OF OPEN WOUND FIRST AID • Pressure bandage • Very occasionally tourniquet • Bony damage splinting

  14. Wound excision • Exploration • Removal of dead, damaged contaminated • Foreign bodies • Arrest bleeding • Restoration of normality

  15. TECHNIQUE • Tourniquet shouldn't be used - Live and dead difficult • But in massive bleeding • Preparation • Irrigation • Enlargement

  16. D) Excision: Principle a. Skin b.Fat c.Fascia d.Muscle –be radical e. Haematomas E) Haemostasis - By packing -Haemostats and ligatures

  17. Management of specialized tissues 1. Nerve:- • identify with a non-absorbable suture 2. Tendon:- • Cover it • Trimmed and repair deferred 3. Bone:- • Cover it • Restore anatomy

  18. 4. Joints • Exception for delayed closure • Infection and adhesion • Antibiotics 5. Blood vessels • Should be repaired FASCIOTOMY- In the whole length of compartment

  19. Hallmarks of modern war injury • Multiple injuries to different body systems • To maim not to kill • Fragments • No Characteristic • Variety of injuries

  20. Features of missile injuries • Low energy- limited injury • Cavitation • In bone creates secondary missiles • Muscles creates the ideal culture medium.

  21. MANAGEMENTOF MISSILE INJURIES Missile wounds of soft tissue - Complete exploration - Delayed primary closure

  22. Stages of operation: 1. Cleaning,incision 2. Deep fascia exposed and incised 3. Neurovascular bundle 4.Removal of foreign matter

  23. 5. Dead Muscle excised; 4 C’s for muscle excision: a. Colour b. Contractility c. Consistency d. Capillary bleeding 6.Tendon ends trimmed

  24. 7. Major artery and vein, trimmed and sutured 8. Bone fragments must not be discarded 9. Injured joints 10. At the end, wound irrigated left open 11. Immobilization 12. Antibiotic cover

  25. Principles of missile injury surgery • Preserve skin • Divide Fascia • Repair vessels not nerves • Remove dead tissue • Stabilize bone with external fixation • Clean and close joint cavities • Leave wounds open

  26. Delayed primary closure • 4-6 days after injury • If wound healthy, delayed pri- closure • Interrupted suture, split-skin graft or both • Traumatic amputations • Surgically tidied • Lowest level • Delayed primary closure

  27. Missile wounds of the abdomen • Nasogastric tube and urinary catheter • Digital rectal • Timing vary • Blood in realistic quantities

  28. High-energy gunshot wound to the abdomen, passing through the liver.

  29. STEPS OF OPERATION: 1. Full midline incision 2. Source of bleeding • Stomach -Inspect posterior gastric wall - opening lesser sac • Retroperitoneal haematoma in duodenal region -Kocher’s method

  30. Retropertoneal haematomas of ascending and descending colon -Exploration • Non-expanding retroperitoneal haematoma over the kidneys -left undisturbed

  31. Wounds of colon and rectum Right side: • Pri repair or pri. resection • Vented ileo tranverse anastomosis

  32. Left side; • One stage procedure • If high risk resected -Proximal colostomy and distal mucous fistula • Hartman procedure • Subsequent restoration

  33. Extra peritoneal rectal injuries: -Sigmoid end colostomy Good dependant drainage -Tip of coccyx and anus Severe • Ligature of internal iliac artery

  34. Renal Injury • Conservatively • Ureter to surface or ‘ a pig tail stent’ • Bladder and urethral injuries • Suprapubic cystostomy • Liver injury • Compression and packing • Drainage of surrounding

  35. Damage to spleen and pancreas • Spleen and tail of pancreas -Resection • Head of pancreas – fatal Peritoneal toilet • Warm saline closure

  36. MISSILE WOUNDS OF THE CHEST • High mortality • Airtight seal • To prevent open pneumothorax • Tube thoracostomy • Prevent accumulation of blood or air • By chest radiography

  37. Entry and exit excised • Opening sealed • Delayed pri. Closure • 20% require formal thoracotomy

  38. Indications (thoracotomy) • More than 1.5 liters initial blood loss • Continuing loss of >200ml/h • Cardiac tamponade • Other mediastinal injuries • Persistent air leak • Retained foreign bodies >1.5c.m. in diameter

  39. MISSILE WOUNDS OF THE HEAD • High energy - lethal • Low energy and tangential - air way, ventilation & maintenance of BP & perfusion pressure • Localise FB and bone fragments • CT • Excision

  40. Irrigation and suction • Temporalis fascia and fascia lata - Close dura • Head and face - Exception of delayed pri.closure • IPPV - Reduces intracranial pressure • Transducers - To monitor ICP

  41. SHOT GUN INJURIES • Excision • Indriven wadding and plugs • Laparotomy • Retention of lead shot • High lead concentration • Will fall

  42. DO’S AND DONTS OF MISSILE INJURIES DO • Incise skin generously • Incise fascia widely • Identify neurovascular bundle

  43. Excise all devitalized tissue • Remove all indriven clothing • Leave wound open • Dress wound • Record all injuries

  44. Dont’s • Excise too much skin • Practice keyhole surgery • Repair tendons or nerves

  45. Remove attached pieces of bone • Close the deep fascia • Insert synthetic prostheses • Pack the wound • Close the skin

  46. BLAST INJURIES • Mechanism • High velocity fragments • Unstable flight & tumbling • New weapons; • Predictable fragmentation • Small, low energy • Incapacitate , not kill

  47. Typical large-fragment wound of the leg Radiograph of mangled leg from blast injury

  48. Two components 1. Blast pressure wave = dynamic over pressure • +ve and - ve phase 2. Mass movement of air = Blast wind

  49. BLAST PRESSURE WAVE • Positve pressure phase; Few milli seconds Upto 7000 KN/m* Over & around an obstruction • Incident pressure – 90* to the direction • Reflected pressure

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