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Management of
Gunshot Injuries
Introduction
In war and troubled times, physicians and surgeons come to treat extensive injuries and mass casualties.
The deal with gunshots and war injuries has its merits and considerations. The surgeons have to operate
in less optimum conditions and less available equipments, and have to deal with patients who suffer
from various sorts of wounds all over their bodies and patients who lost considerable amounts of
their blood and body fluids to the extent that puts their lives at high risk. During under- and post-
graduate training, very few surgeons worldwide have been exposed or dealt with gunshots or war
injuries. However, the basic principles of wound management and care remain more or less the same
regardless to the etiological variables. Lessons from the past should be documented and learned and
the experience should be passed among surgeons who deal with these cases.
38 Smile Magazine
Type of Injury Cases Percent Type of Injury Cases Percent
Live Bullet 1406 72.7 Live Bullet 6344 18.9
15 1 0
Total 33527 100
Missing System 1 0
Smile Magazine 39
Surgery
However, Sellier in 1967 showed in his work Treatment of gunshots in the head
on gunshots using high-speed camera, and neck
that the circular loss of epidermis around Initial or immediate management: at
the entrance wound was caused by this stage the A, B, C, D, E, principles of
superficial tissue particles being thrown Advanced Trauma Life Support (ATLS)
back against the direction of fire. should be applied. These include; A:
securing Airway and stabilizing the cervical
Bullet exit hole is usually larger than the spine, B: Breathing, C: Circulation, D:
entrance hole and more tissue loss and neurological Deficit and E: Exposure.
laceration.
The second stage, which is the definite
Considerations of gunshots in the head treatment stage, should be carried out,
and neck region once the initial management has been
Injuries in the head and neck region have satisfactorily achieved and the patient is
their own considerations due to the local stable and secure, all the investigations
anatomy. The head and neck region needed to estimate the extent of
includes many vital organs and structure injuries, reach full diagnosis, and put
and contains the air and food entrance to extensive treatment plan, has been done
the body. including plain X rays and CT scans. In
our experience, this stage should be
Death due to gunshot injuries in the head performed at the earliest possible time.
and neck region can prevail due to It has been noticed, that the earlier the
many different causes, including direct bone fixation and the soft tissue wounds
brain trauma, bleeding from major blood closed are performed, the better the
vessels like carotid arteries or jugular veins, achieved outcome in aspects of bone
airway obstruction by blood clots, foreign and soft tissue healing and the incidence
bodies or laryngeal or tracheal damage. of postoperative infection. Sometimes, this
stage is performed on the same day of
Impairment of function can be due to injury if the circumstances allow.
loss of eyes, damage to ears, larynx or
esophagus. Loss of teeth, part of jaw At the second stage, wound debridement
bones or tongue can also cause severe is done; all necrotic soft tissues are
functional involvement to the affected excised, necrotic and doubtful bone
patient. Neurological impairment results pieces and are also removed from
from nerve damage in the region, like the wound site. All shrapnel and bullet
facial nerve, trigeminal nerve, hypoglossal fragments dusts and other dirt and foreign
nerve, optic nerve, vagus nerve or due to debris that could be seen and removed
brain damage. Serious and permanent without risking vital structures must be
disability can happen due to cervical cleaned from the injury site to reduce
spine damage; one case we treated the risk of infections. The area is washed
in 2002, where 16 years old male who with copious amounts of normal saline to
received live bullet to his neck which make sure all necrotic free particles are
went through his larynx and external have been completely cleaned from the
carotid artery. After working several hours wound. All viable bone pieces must be
in theatre and giving him more than 6 put back together and fixed with as rigid
units of blood, bleeding was controlled, fixation as possible. It has been found
his larynx was repaired, but he ended from our practice, that the more rigid the
with quadriplegia, because the bullet fixation is, the better the bone healing
damaged part of his spinal cord. and the fewer the incidence of infection.
Therefore, non-rigid fixation like osseous
Aesthetic disfigurement is an important wires is not recommended and should
factor that should be considered be avoided. In case of comminuted
in treating facial injuries due to its mandibular fracture, where the fragments
psychological impact on the affected are held strongly enough together by the
patients. periosteom, IMF for a period of 6 weeks
can a satisfactory measure of treatment
after closing all soft tissue wounds.
40 Smile Magazine
During and after all treatment stages,
prevention of infection and its control
when it happens are as important as
the surgical procedures. The first step in
prevention of infection is to remove all
possible causes during surgery including
bullets, shrapnel, and necrotic soft and
hard tissues. Proper broad spectrum
antibiotic cover should be given
intravenously and then orally for a long (Figure 5)
enough period to prevent infection. In Rigid fixation of
our protocol, the patients are usually gunshot in the
given amoxicillin with clavulanic acid and mandible
metronidazole. If infection is encountered References
during the course of treatment, swab 1. W. Weimann, Zur Wirkung und gerichtsärzlichen
is taken for culture and sensitivity and Beurtilung der Scheintod pistolen, Arch. Kriminol. 80
antibiotic is prescribed accordingly. (1972) 40-48.
Needless to say the importance of local 2. S.E. Dana, VJM DiMaio, Gunshot trauma in. : J
wound hygiene and good oral hygiene Payne-James, A. Bussutil, W Smock (Eds), Forensic
using regular mouthwashes and tooth Medicine: Clinical and Pathological aspects,
brushing in prevention of secondary Greenwich Medical Media, London 2003, 149-
infections. 158.
3. K Sellier, Schusswaffen und Schusswirkungen.
Third stage (Reconstruction Stage): this Ballestic Medizin und Kriminalistic, Schmidt-
stage usually starts after the second stage Römhild, Lűbeck, 1969, pp. 142-148, 213-220.
is completed. The patient is fully assessed 4. K. Sellier, Einschusstudien an der Haut, Beir, Gerichtl,
regarding the secondary defects. The Med. 25 (1969) 265-270.
treatment includes reconstruction of hard 5. S. Pollack, M.A.Rothcshild, Gunshot injuries as a
and soft tissues using different types of topic of medical research in the German-speaking
bone grafts and soft tissue flaps including countries from the beginning of the 20th century
local, distant and free vascular flaps. up to the present time. Forensic Sc. Int. 144 (2004)
201-210.
Fourth stage (Rehabilitation): it includes
functional and psychological rehabilitation
of patients. At this stage replacement of
missing teeth and supporting hard and
soft tissues is done using maxillofacial and Author: Dr. Raed Taleb Al-Jallad
dental prosthesis and dental implants.
• B.D.S (Jordan), M.Sc (Manch.),
Conclusion • F.F.D.R.C.S. (Irle.), F.D.S.R.C.S. (Eng.)
treatment of gunshot injuries should • Consultant and Head of Department of
be planed and carried out carefully. It Oral and Maxillofacial Surgery - Makassed
takes different stages and procedures Hospital.
to achieve the targeted treatment plan, • Assistant professor in head and neck anatomy,
Faculty of Medicine - Al-Quds University.
Bone fixation and wound closure should
• Assistant professor in Oral and Maxillofacial
be done at the earliest possible chance.
Surgery, Faculty of Dentistry - Al-Quds
Prevention and control of infection are University.
important in the success of the treatment. • raedjallad@hotmail.com
Smile Magazine 41