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Penetrating Trauma to the Extremities

Penetrating Trauma to the Extremities . Steven Issley, MD Emergency Medicine McGill University May 8, 2002. Outline. Ballistics Vascular injury Orthopedic injury Antibiotics Wound care. Ballistics: temporary cavity. Ballistics: energy. E = 1/2 mv 2. Ballistics: energy. E =

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Penetrating Trauma to the Extremities

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  1. Penetrating Trauma to the Extremities Steven Issley, MD Emergency Medicine McGill University May 8, 2002

  2. Outline • Ballistics • Vascular injury • Orthopedic injury • Antibiotics • Wound care

  3. Ballistics: temporary cavity

  4. Ballistics: energy E = 1/2 mv2

  5. Ballistics: energy E = 1/2 mv2 Low velocity <2500 fps High velocity >2500 fps

  6. Ballistics: types of firearms • Handguns: low velocity • 38mm 600-870 fps • 9mm 860 fps • 22mm 1200 fps • Military: high velocity • M16 3250 fps • AK47 2340 fps • Shotguns: low velocity*** • 1100-1500 fps

  7. Ballistics: shotguns

  8. Ballistics: knife wounds • Slash • Stab • No indirect tissue damage

  9. Ballistics: documenting exam • Entrance / exit wounds • How many wounds • Location • Size, depth, shape • Injuries: detailed neurovasc • State of clothes • Identify and keep missiles • write only on base or tip to maintain rifling • DOCUMENT OBJECTIVELY!

  10. Vascular injury: anatomy

  11. Vascular injury: hard signs • Hemorrhage: pulsatile or exsanguinating • Expanding hematoma • Bruit • Thrill • Ischemia (“6 P’s”)

  12. Vascular injury: soft signs • Hx of significant hemorrhage • hematoma: small, non-expanding • Neurologic deficit (non-progressive) • Proximity

  13. Vascular Injury • Complications: • hemorrhage • thrombosis / emoblism • aneurism / pseudoaneurism • compartment syndrome • Venous injury

  14. Vascular: investigations • ???? none • Frykberg ‘ 91: • No sx ’s: D/C home • Proximity+ No sx ’s: obs x 24h • <1% missed; no morbidity • Gonzalez ‘ 99: • Proximity, no hard signs • 24h obs = 1% missed; • no morbidity • Pressure Index: Arterial or Doppler (API, DPI) • sens: 45-95% for wounds requiring OR

  15. Vascular: investigations • Arteriogram • Sens: 98% • Spec: 99% • Too Sens: 4% False Pos --> unecessary OR • Expensive • Thrombosis / allergic reaction • Dupplex • sens: 50-60% (comp. to angio) • sens: 100% (wounds req. OR) • spec: 99-100%

  16. Vascular: investigations • New Kids On The Block: • CT angio • sens: 90% • spec 100% • MRI

  17. Algorithm Hard signs Shotgun II, III *High energy Destruction Soft signs API<0.9 Proximity *Shotgun I *High energy - Sx ’s - Proximity IPA>0.9 Normal exam ±Angio Obs 24h + - Angio/US + - OR Home

  18. Orthopedic injury: bone • Low velocity • Drill Hole • Divot • High Velocity • complicated • comminuted • Fragments act as 2o missiles • Stab wounds

  19. Orthopedic injury • Joints • Lead Toxicity • Nerves

  20. Antibiotics: wound infection • Bacrterial innoculum • Devitalized tissue • Age of wound • Location of wound • Foreign bodies • Immune compromize

  21. Antibiotics • Lacs and Stabs • ???Sterile bullets • GSW • Low energy • High energy • Shotguns

  22. GSW wound care: indications for OR • Hard signs • Progressive neuro deficit • Open fracture • Unstable fracture • Significant soft tissue damage or necrosis • Compartment syndrome • Shotgun II, III • >8h post-injury

  23. Wound care What about the bullet?

  24. Summary • ATLS • Tetanus • Indication for OR? Stable / unstable? • Further investigations? • Wound care • Antibiotics? • Bonjour la visite!

  25. References • Arrillaga A, Nagy K, et al. Practice Management Guidelines forPenetrating Trauma to the Lower Extremity. EAST Trauma Practice Guidelines. http:\\www.east.org . • Barlett CS, Helfet DL. Ballistics and Gunshot Wounds : Effect on Musculoskeletal Tissues. J Am Acad Ortho Surgeons. 8(1) : Jan/Feb 2000. • Dake AD, Stack LS. Penetrating Trauma to the Extremities: Systematic Assessment and Targeted Management of Weapons-Related Injuries. Emergency Medicine Reports. March 31, 1997. • Fesmire FM, Dalsey WC, et al. American College of Emergency Physicians: Clinical Policy for the Initial Approach to Patients Presenting With Penetrating Extremity Trauma. Annals Emerg Med 33(5):612-36. May 1999. • Frykberg ER, Dennis JW. The Reliability of Physical Exam […] Vascular Injury: Results at One Year. J Trauma. 31(4):502-11. Apr 1991. • Gonzalez RP, Falimirski ME. Th Utility of Physical […] Penetrating Extremity Trauma. Am Surg. 65(8): 784-9. Aug 1999. • Leibner EC, Jackimczyk K. Penetrating Extremity Trauma : The Problem of Occult Vascular Injury. Emergency Medicine Reports. Jan 11, 2001. • Rathlev N. Peripheral Vascular Injuries. eMedicine Journal. 2(6): June 22, 2001. • Newton E. Peripheral Vascular Injuries in Rosen `s Emergency Medicine : Concepts and Clinical Practice, 5th Ed. Mosby: 2002. • http:\\www.trauma.org

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