Academic literature on the topic 'Bullet wound trauma'

IntroductionPenetrating wounds from explosively propelled fragments and bullets are the most common causes of combat injury. There is a requirement to assess the potential effectiveness of bullets penetrating human tissues in order to optimise preventive measures and wound trauma management.MethodsAn advanced voxel model based on the Chinese Visible Human data was built. A digital human vulnerability model was established in combination with wound reconstruction and vulnerability assessment rules, in which wound penetration profiles were obtained by recreating the penetration of projectiles into ballistic gelatin. An effectiveness evaluation method of bullet penetration using the Abbreviated Injury Scale (AIS) was developed and solved using the Monte Carlo sampling method.ResultsThe effectiveness of rifle bullets was demonstrated to increase with increasing velocity in the range of 300–700 m/s. When imparting the same energy, the effectiveness of the 5.56 mm bullet was higher than the 7.62 mm bullet in this model.ConclusionsThe superimposition of simulant penetration profiles produced from ballistic gelatin simulant has been used to predict wound tracts in damaged tissues. The authors recognise that determining clinical effectiveness based on the AIS scores alone without verification of outcome by review of clinical hospital records means that this technique should be seen more as a manner of comparing the effectiveness of bullets than an injury prediction model.

In 1999, Caruso reported data from the level 1 trauma center in Newark, New Jersey, documenting “. . . an ominous trend toward the use of larger caliber firearms in accidents, homicides and suicides.” Those data were derived from measurements of bullets removed from our trauma patients and submitted to the Surgical Pathology laboratory from 1981 through 1997. We further document this trend with measurements of similar source bullets from 1998 through 2002. During the same time, we recorded mortality among gunshot wound victims treated at our trauma center. Bullets submitted to surgical pathology during the years 1998 through 2002 were measured with a millimeter rule to determine caliber or transverse diameter. A total of 367 bullets were studied in this 5-year period. Bullets deformed beyond measurability (∼22%) and shotgun pellets (<5%) were excluded from our study. Bullet calibers were expressed in terms of mean plus or minus standard error ([Formula: see text] ± SE). Mortality figures were derived from analysis of medical records concerning the outcomes all victims of gunshot wounds (E 922, E 965) treated at our hospital during the years studied and expressed as percentages. Linear regression of mean bullet caliber over time was performed, and analysis of variance was used to assess statistical significance of apparent differences in mortality. Bullet caliber continued to increase from 8.47 ± 0.22 to 9.16 ± 0.15 mm during the 5-year observation period. Linear regression reveals R = 0.9649, P < 0.01. Mortality ranged from 4.7 per cent to 10.7 per cent but the differences were not significant ( P > 0.20). These data support a continued trend toward the use of larger caliber firearms in accidents, homicides, and suicides. Mortality does not change during this time and presumably because of improvements in treatment, from resuscitation to definitive surgery and its convalescence.

We describe the management of bullet embolism from a penetrating cardiac injury, including the clinical, radiographic, and operative considerations in this challenging trauma scenario. Bullet embolism represents a rare but complex subset of ballistic penetrating trauma, and highlights the importance of radiographic correlation with intraoperative findings.

Penetrating tracheal trauma, although infrequent, varies from minor to life-threatening injuries. Serious injury often results from airway compromise or significant associated esophageal or vascular trauma. Tracheal injuries resulting in a retained ballistic fragment in the airway have been infrequently reported. We report the successful treatment of a patient with a gunshot wound to the anterior cervical trachea resulting in a spent bullet lodged in the left lower lobe bronchus.

Category: Trauma Introduction/Purpose: Gunshot wounds are common injuries encountered by orthopaedists in urban settings. Retained missiles can lead to significant morbidity and functional impairment. Despite the potential for adverse sequelae, controversy remains regarding the role of routine bullet removal. Suggested indications for bullet removal include those leading to infection and lead toxicity. Bullets located in the palm of the hand, sole of the foot, or intraarticularly are commonly removed as well. Given the unlikeliness of a retained missile sparing the many joints or sole of the foot, we question the indications for conservative management. The purpose of this case series of is to further develop indications for bullet removal from the foot. Methods: A medical record search was performed at a single one trauma institution, with high volume of patients with ballistic injury, for patients who underwent bulletectomy from 2008 until 2018. Of the 169 patients originally obtained, 17 patients underwent bulletectomy, with associated irrigation and debridement, of the foot and ankle. The record of each patient in this retrospective case series was individually reviewed for location of retained missile, indications for removal, whether the procedure was performed at the bedside or in the operating room, concomitant injuries or surgeries, and follow up. Results: Of the 17 patients with retained bullets removed from the foot and ankle, four (23.5%) were removed at the bedside versus the operating room. Indications for removal were painful palpable subcutaneous position of the bullet (11 or 64.7%), periarticular or intraarticular bullet (five or 29.4%), and infected wound with removal of foreign body to optimize healing (one or 5.9%). The location of the palpable missiles included three on the plantar foot, four on the dorsal foot, and four located in subcutaneous tissues adjacent to the ankle joint. Nine out of seventeen (52.9%) had fractures associated with the retained missile. Of the patients with OR procedure (13), the majority of them (nine or 69.2%) were in the operating room for another procedure as well. Conclusion: The indications for bulletectomy of the foot and ankle are not definite, however, it is recommended that bullets located in the weightbearing plantar foot or intraarticularly be removed. After analysis of a seventeen patient retrospective case series, we support these indications but also advocate for the removal of any painful subcutaneous or periarticular bullet, whether under local anesthesia or in the operating room. In our experience, the prominent foot and ankle bullet is often removed during a procedure for another anatomic site. Bulletectomy of the foot and ankle in a stable polytrauma patient should be considered.

Atypical gunshot wounds present a challenge for the forensic expert, and sometimes differentiating these from a blunt trauma can be difficult. A careful crime scene investigation can be helpful in finding additional evidence and clarifying the nature of the injuries. We describe a case of an unusual craniocerebral injury that was initially interpreted as a blow from a wooden object. The appearance of the wound lacked the classical characteristics of entrance and exit bullet wounds, but the investigation showed it was due to the ricocheting of a destabilized bullet. Potentially lethal, craniocerebral gunshot injuries are a common occurrence in developing countries even in non-conflict areas, with very bad outcomes even when treated aggressively in specialized neurosurgical facilities. The authors briefly discuss similar cases and opinions in the relevant literature, emphasizing the importance of a rational approach during the reconstruction of the crime scene.

Maxillofacial ballistic trauma represents a devastating functional and aesthetic trauma. The extensive damage to soft and hard tissue is unpredictable, and because of the diversity and the complexity of these traumas, a systematic algorithm is essential. This study attempts to define the best management of maxillofacial ballistic injuries and to describe a standardized, surgical and prosthetic rehabilitation protocol from the first emergency stage up until the complete aesthetic and functional rehabilitation. In low-velocity ballistic injuries (bullet speed <600 m/s), the wound is usually less severe and not-fatal, and the management should be based on early and definitive surgery associated with reconstruction, followed by oral rehabilitation. High-velocity ballistic injuries (bullet speed >600 m/s) are associated with an extensive hard and soft tissue disruption, and the management should be based on a three-stage reconstructive algorithm: debridement and fixation, reconstruction, and final revision. Rehabilitating a patient with ballistic trauma is a multi-step challenging treatment procedure that requires a long time and a multidisciplinary team to ensure successful results. The prosthodontic treatment outcome is one of the most important parameters by which a patient measures the restoration of aesthetic, functional, and psychological deficits. This study is a retrospective review: twenty-two patients diagnosed with outcomes of ballistic traumas were identified from the department database, and eleven patients met the inclusion criteria and were enrolled.

The frequency of thoracic injuries in the general structure of combat surgical trauma remains at the level of 7-12 % and unchanged from the time of the Second World War to the current armed conflicts. The overwhelming majority of them (up to 72 %) are shrapnel gunshot wounds. The formation of a gunshot wound occurs due to the action of a shock wave; a wounding projectile; energy of side impact and vortex wake. The shape, size, features of the wound canal are determined by the kinetic energy of the wounding agent and the physical properties of the damaged tissues. The lung parenchyma is loose and elastic, so small-caliber bullets with low energy cause minimal damage. The wound canal is well differentiated on CT-slices. Its cavity is filled with blood, fragments of destroyed tissue, air bubbles. On the periphery, the contusion zone is determined (area of increased attenuation in the lung-ground-glass opacity). Shrapnel wounds can be accompanied by ruptures of the pulmonary parenchyma with hemorrhages, bilateral pulmonary contusion, damage to the bone frame and soft tissues of the chest. Vascular injury with massive hemorrhage into the pleural cavity and tense hemopneumothorax are one of the main causes of mortality in penetrating wounds. Transmediastinal gunshot wounds, armor trauma and bullet embolism require special attention during radiation examination of victims. The purpose of radiation diagnostics of modern combat trauma is to identify and fully characterize injuries and their complications. The amount of diagnostic information is determined by the level of medical care. Key words: gunshot wounds, chest cavity organs, radiation diagnostics.

Abstract BACKGROUND Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. OBJECTIVE To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. METHODS From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. RESULTS Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. CONCLUSION Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.

Background It is hypothesised that an anatomical simulant model, that replicates the heterogeneous nature of human organs and tissues, will provide a more reliable and accurate method of evaluating the pathological features and incapacitation potential of ammunition in a weapons system than homogeneous bare ordnance gelatine alone. The use of frozen and thawed cadavers for simulant development was also examined. To develop a model, the most critical organs and tissues that sustain bullet wound trauma within the thorax and abdomen must be determined. Next a suitable method for establishing and matching the relevant biomechanical properties with candidate simulant materials must be developed, and an appropriate scoring system adopted. Method De-identified wound trauma data from 197 homicidal gunshot post mortem examinations in Israel were obtained between 2000-2001 and 2004-2008. The corresponding forensic ballistics data was only available for the cases between 2004 and 2008. The major organs involved, type of wounds, cause of death (COD), most common bullet paths, distances involved, firearm calibres and bullet types were established. Tensile strength tests were undertaken on selected tissue samples from an un- embalmed cadaver that had been frozen and thawed five times, which maximised the effects of repeated cycles. The universal test equipment Hounsfield H50KM machine was used to apply uniaxial tension until tissue failure occurred. The maximum tensile strength results in g/mm² were compared against corresponding data from the literature. Energy loss tests were conducted on fresh porcine organs/tissues using steel 4.5mm BB pellets fired from a Daisy® brand air rifle. Each organ/tissue was tested at room temperature and 37°C (body temperature). They were compared to Federal Bureau of Investigation (FBI) and North Atlantic Treaty Organisation (NATO) specification ordnance gelatine, as well as a candidate simulant material. A limited number of tests were also conducted at 4°C for further comparison purposes. Two chronographs measured BB pellet velocity before and after each test material was perforated and the difference was established in m/s. The resulting energy loss was established using the formula KE = ½ mv². FBI and NATO specified ordnance gelatine of 250 and 285 Bloom strengths were manufactured using tap water, reverse osmosis (RO) water and de-ionized water. They were allowed to cure for 21 hours, 100 hours and 3 weeks. The FBI calibration standard was used for all formulations as there is no separate standard for the NATO formulation in the literature. An Australian Defence Force (ADF) AUSTEYR model F88 ICW (individual combat weapon) in calibre 5.56x45mmNATO was used with standard issue ASF1 ball ammunition. Large FBI specification ordnance gelatine blocks were manufactured and thin gelatine/composite plates were used to simulate subcutaneous tissue and fat, as well as to provide a platform for the attachment of a skin simulant and to embed bone/rib composite within. A 250mm air gap and bubble wrap was used to simulate an expanded lung. The gelatine/composite plates were secured to a wooden cradle and the gelatine blocks were positioned behind it. The F88 ICW was fixed in a remote firing device 50m from the target and a chronograph 3m in front of the rifle measured bullet velocity. Test results were recorded using two high speed ‘Photron Fastcam’ digital cameras. Maximum three dimensional permanent cavity dimensions were obtained using a vernier gauge, and temporary cavity measurements were taken from high speed video images. Results The homicide study established that males represent 91% of gunshot victims. Of the 999 bullet wounds recorded, males were struck in the body an average of 5.2 occasions, with 2.2 of these bullets striking the thorax and/or abdomen. A contributing factor to the frequency of bullet strikes was the type of firearms involved, namely semi automatic pistols in the predominant calibre 9mm Luger, and assault rifles in calibre 5.56x45mm and calibre 7.62x39mmSoviet. Full metal jacket bullets were used in most instances and the majority of shootings (N=124) occurred at ranges estimated at 1m or greater. The most common bullet path was front to back in 66% of cases, followed by back to front in 27% of cases. Entry wounds occurred more often on the left side of the thorax, abdomen and back (N=253) compared to the right (N=172). The most common critical organs/tissues to sustain bullet trauma in descending order were; heart, lungs, liver, aorta, spleen, kidneys and vena cava. Ribs were struck by most bullets that entered the thorax. Multiple organ injury was listed in 146 of the 192 cases where a specific COD was determined by the pathologist. The following tensile strength results were achieved from the cadaver study: heart 3.56g/mm², kidney 10.27g/mm², oesophagus 22.08g/mm², skeletal muscle 29.46g/mm², ascending aorta 59.98g/mm², trachea 155.40g/mm², spleen 4.65g/mm², liver 10.83g/mm², pancreas 15.18g/mm², lung 29.94g/mm², pericardium 136.84g/mm², skin (abdomen) 355.26 g/mm² and skin (thorax) 407.88g/mm². These data were compared to published results obtained from non-frozen tissues from elderly persons, recognising that tensile strength values were only available for the following organs and tissues at the 95% degree of confidence: heart 9.2±0.95g/mm²; kidney 4±0.20g/mm², oesophagus 51±1.1g/mm², skeletal muscle 9±0.30g/mm², ascending aorta 68±2.4g/mm², trachea 150±6.5g/mm². It can be seen that some results from the test cadaver were higher and some lower than the published results, with trachea recording the only similar result. This indicates that the freezing and thawing process may change the tensile strength of tissues in unpredictable ways. Therefore, bio- mechanical research should avoid the use of frozen/thawed tissues and organs. The major agreement between the porcine energy loss tests were: FBI specification gelatine was similar (p>0.05) to heart and lung at room temperature and 37°C; spleen was similar to NATO specification gelatine at room temperature and 37°C; candidate Simulant ‘A’ was similar to hindquarter muscle at room temperature and 37°C and hindquarter muscle, kidney and spleen were similar to each other at room temperature and 37°C. Liver and kidney, and liver and fat were similar to each other at 4°C. The use of different water types had no effect upon ordnance gelatine calibration results. However, different temperatures, concentrations and curing times did have a significant effect. Neither of the two NATO 20% formulations met the same calibration standard as the FBI 10% formulation. The penetration depths achieved for the FBI formulations at both 3°C and 4°C were closest to the recommended calibration standard after 3 weeks curing time. A 20% concentration of 285 Bloom at 20°C met the same FBI calibration standard after 100 hours of curing and can be considered comparable. The anatomical model pilot tests demonstrated the benefit of using simulants that are more representative of the heterogeneous nature of human organs/tissues. It was found that by combining skin, bone and other simulant materials with ordnance gelatine, the behaviour of a military full metal jacket (FMJ) rifle bullet changes with regard to the earlier onset of temporary cavitation, reduced penetration depth and a higher degree of bullet yaw compared to simulations using only bare FBI specification ordnance gelatine. This occurs because more energy is consumed negotiating the various anatomical simulants, which means wounding is likely to occur much earlier, and organs that are deeper within the body may not be affected to the same degree. These factors will impact significantly upon injury severity in real tactical scenarios. Conclusion The experimental studies provide the framework for the development of a heterogeneous model for bullet trauma simulations of the thorax and abdomen. This model would be more representative of actual wound trauma than bare ordnance gelatine alone. This conclusion was arrived at by identifying the most critical organs/tissues for modelling purposes. Their energy loss values (J/m) were established and the method adopted allows for comparable simulants to be developed. Porcine energy loss tests showed that FBI specification gelatine is similar to heart and lung, but different to hind quarter muscle and most of the other ‘critical’ organs and tissues within the thorax and abdomen. NATO specification gelatine is a suitable simulant for spleen, and test Simulant ‘A’ is a suitable simulant for both hindquarter muscle and kidney. A separate simulant would be required for liver, fat and aorta. Frozen and thawed cadaveric tissue was shown to produce unpredictable tensile strength data and is therefore unsuitable for simulant development. The limitations of using FBI and NATO specification ordnance gelatine was highlighted when changes to bloom number, temperature and curing times altered calibration results. Therefore, temperature stable synthetic simulants such as Simulant ‘A’ are preferable. The anatomical model pilot tests clearly demonstrated that the addition of simulant materials directly affects wound severity simulations compared with bare ordnance gelatine alone. This in turn affects interpretation of real life situations. The AIS 2005/2008 and MAXISS scoring systems are deemed appropriate to grade the lethality potential of model simulations. Therefore, the original hypothesis has been validated.
Thesis (Ph.D.) -- University of Adelaide, School of Medical Sciences, 2014.

Bullets and other projectiles cause ballistic trauma. Explosions wound by the effect of a blast pressure wave, penetrating fragments propelled by the explosion, the mass movement of gas interacting with the casualty or the environment, and miscellaneous effects. Most blast casualties surviving to hospital care will not have significant pressure wave injury, but some will. Blast fragmentation most commonly resembles other types of low energy transfer ballistic trauma.. The effect of bullets depends on the kinetic energy transferred and the nature of the tissues struck, with energy transfer partly determined by bullet design. Low energy transfer bullets wound by crushing and laceration, limited to the tissues struck. High energy bullets may impart kinetic energy to surrounding tissues, causing a temporary cavity which sucks in debris and damages tissues sometimes well beyond the bullet track. Predicting the extent of devitalization can be difficult at the time of initial inspection. Wound contamination, particularly with soil, may modify the usual conservative approach to initial debridement.

The severity of ballistic trauma is dependent upon multiple factors including bullet type, velocity, tissue type penetrated, and energy transfer. Patient management needs a considered approach with careful assessment, appropriate imaging and directed treatment of the wounds found. Triage, treatment and transport form the framework of effective prehospital care. In the emergency department a rapid primary survey is essential to reveal any injuries that need immediate intervention. The decision to operate and nature of surgery is determined by the patient’s suspected injuries, physiological condition and expertise available with some patients benefiting from damage control resuscitation and surgery. Indications for intensive care admission include the need for ongoing organ support, cardiovascular instability, and injuries that require close observation. Attention should be paid to cardiovascular status, coagulation, nutrition, thromboprophylaxis, infective issues, and management of specific injuries. Patients may require protracted hospital stays and extensive reconstructive surgery. The psychological and social impact of these injuries should not be underestimated.

This book draws on the latest research about identifying and treating the pain of perpetration to advance and deploy a literary theory of moral injury that addresses fictional representations of the mental anguish of those who have injured or killed others. The book foregrounds moral injury, a recent psychological concept distinct from trauma that is used to describe the psychic wounds suffered by those who breach their own deeply held ethical principles. Complementing writings on trauma theory that posit the textual manifestation of trauma as absence, the book argues that moral injury appears in literature in a variety of forms of excess. The author closely reads works by Dostoevsky (Crime and Punishment), Camus (The Fall), and veterans of the wars in Iraq and Afghanistan (Brian Turner's Here, Bullet; Kevin Powers' The Yellow Birds; Phil Klay's Redeployment; and Roy Scranton's War Porn), contending that recognizing and understanding the suffering of perpetrators, without condoning their crimes, enriches the experience of reading — and of being human.