dr younas assistant professor peshawar dental college pakistan

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4. MANAGEMENT OFMANAGEMENT OF
GUNSHOT INJURIESGUNSHOT INJURIES
Dr. MUHAMMAD YOUNASDr. MUHAMMAD YOUNAS
TMO ORAL SURGURYTMO ORAL SURGURY

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INTRODUCTION
 The greater the ignorance the greater the dogmatism
(William Osler)
 The most worst injuries depending upon the range,
velocity and caliber of the shot
 Typically involved both soft tissue and bones
 Wounds caused by gunshot lead to unique and complex
injury patterns

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PHYSICS OF THE GUNSHOT WOUNDS
 Wounding capacity depends upon kinetic energy
impact
 K.E =
 Wounding power
 Velocity determine the wounding capacity
 Injury caused by a bullet is directly proportional to
the amount of energy transferred and to the actual
energy expended
2
2
1
mv
2
)( exitimpact VVmP −=

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MECHANISM OF GUNSHOT INJURIES
 Components of projectile wounding
1. Penetration (transfer destructive energy to
surrounding tissue)
2. Permanent cavity formation
3. Temporary cavity formation
4. Fragmentation (primary, secondary)

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FACTORS AFFECTING THE DEGREE
OF INJURIES
 Velocity of bullet
 Size of bullet
 Drag and retardation
 Composition of bullet (single, multiple)
 shape of the bullet
 Extent of cavitations that occurs
 Deviation (yaws)

9. CLASSIFICATION OF GUNS ON THE
BASIS OF VELOCITY
 Low velocity (< 350 m/s).
 Medium velocity (350-600
m/s)
 High velocity (> 600 m/s)
 Velocity approximately 50 m/s
is required to penetrate the
skin
 65 m/s fracture the bone

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12. Rifle has high velocity
Piston has medium velocity
(hand gun)
Revolver has low velocity

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14. COMPOSITION OF BULLET
Shape and consistency of
bullet determine the nature of
wound
Bullet alloy composition 2%
tin, 6% antimony and 92%
lead

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FIREARM TERMENOLOGYFIREARM TERMENOLOGY
 BALLISTICSBALLISTICS (science of projectile motion)(science of projectile motion)
 Relating to or characteristic of the motion of objects moving underRelating to or characteristic of the motion of objects moving under
their own momentum and the force of gravity; "ballistic missile"their own momentum and the force of gravity; "ballistic missile"
 Handguns (pistol, revolvers)Handguns (pistol, revolvers)
 RiflesRifles
 ShotgunsShotguns
 Yaw (oscillation around the long axis of the bullet)Yaw (oscillation around the long axis of the bullet)

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CLASSIFICATION OF GUNSHOTCLASSIFICATION OF GUNSHOT
WOUNDSWOUNDS
1.1. Based on the velocity (energy transferred)Based on the velocity (energy transferred)
 Low energy transfer woundsLow energy transfer wounds
 High energy transfer woundsHigh energy transfer wounds
 Middle energy transfer woundsMiddle energy transfer wounds

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CLASSIFICATION OF GUNSHOTCLASSIFICATION OF GUNSHOT
WOUNDSWOUNDS
2.2. Simplest classification schemeSimplest classification scheme
A.A. Penetrating woundsPenetrating wounds
 low velocity projectilelow velocity projectile
 embedded in the tissueembedded in the tissue
 small point of entrysmall point of entry
 Examples handguns bullet (release energyExamples handguns bullet (release energy
100-500J)100-500J)
B.B. Perforating woundsPerforating wounds
 High velocity (high energy transfer wounds)High velocity (high energy transfer wounds)
 Exit wound larger than entryExit wound larger than entry
 In and outIn and out
 Examples rifles bullet woundsExamples rifles bullet wounds

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C.C. Avulsive woundsAvulsive wounds
 Loss of tissueLoss of tissue
 Irregular fragments from bombsIrregular fragments from bombs
grenadesgrenades
3.3. Gugala and Lindsey classificationGugala and Lindsey classification
1.1. High or low energy woundsHigh or low energy wounds
2.2. Involvement of vital structure (neuralInvolvement of vital structure (neural
and vascular)and vascular)
3.3. Wound type (non-penetrating,Wound type (non-penetrating,
penetrating, perforating)penetrating, perforating)
4.4. Fracture (intra-articular and extra-Fracture (intra-articular and extra-
articular)articular)
5.5. contaminationcontamination
CLASSIFICATION OF GUNSHOTCLASSIFICATION OF GUNSHOT
WOUNDSWOUNDS

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Avulsive wounds

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Wounds
ENTRY WOUND
Smaller size
If at contact blast skin
.
Inverted margins.
Abrasion collar
present
EXIT WOUND
tear of tissues
Split outward skin
Everted margins
Abrasion collar
absent

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Wounds
ENTRY WOUND
Burning
/blackening /singing
/tattooing seen
Laed ring seen
EXIT WOUND
No such
phenomenon seen
Lead ring not seen

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Left neck entry pointLeft neck entry point

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MANAGEMENTMANAGEMENT
General principles (ATLS protocol)General principles (ATLS protocol)
 Rule out (look for)Rule out (look for)
 multiple injurymultiple injury
 inspection of entrance and exit point (multiple)inspection of entrance and exit point (multiple)
 Penetrating, perforating, avulsive woundsPenetrating, perforating, avulsive wounds

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MANAGEMENTMANAGEMENT
 17 % patient of GSW to the face have associated17 % patient of GSW to the face have associated
brain injuriesbrain injuries
 8 % C-spine injuries8 % C-spine injuries
 13 % eye injuries13 % eye injuries

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EMERGENCY TREATMENT OREMERGENCY TREATMENT OR
IMMIDIATE POST TRAMATIC PHASEIMMIDIATE POST TRAMATIC PHASE
A.A. AIRWAY (single most cause of death inAIRWAY (single most cause of death in
GSW to theGSW to the face)face)
 Emergency intubations (25-36%)Emergency intubations (25-36%)
 Mandible wounds rate of intubations (37-Mandible wounds rate of intubations (37-
53%)53%)
 Mid face (18-36%)Mid face (18-36%)
 Cricothyroidotomy (tracheal)Cricothyroidotomy (tracheal)
 tracheostomytracheostomy
B.B. BreathingBreathing
C.C. circulationcirculation

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D.D. Hemorrhage ControlHemorrhage Control
– Direct pressureDirect pressure
– PackingPacking
– Epistaxis control (foley, balloon catheters)Epistaxis control (foley, balloon catheters)
– Reductions of fracture segmentReductions of fracture segment
– Angiography and embolizationAngiography and embolization
– Ligation and tying offLigation and tying off
EE.. AnalgesiaAnalgesia

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IMMAGING
 Plain Radiographs
1. C-spine views
2. Chest radiograph
3. PA view of face
4. Lateral view of face
5. PNS (water) view
 CT scan
 3-D CT scan
 CT-Angiography
 ultrasonography

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KAZANJIAN -PHASE APPROACH (MANGMENT)
PRIMARY SURGICL PHASE
A. Wound toilet
B. Conservative debridement (removal of devitalize tissue)
C. Removal of teeth (extensive damage)
D. Wound evaluation and exploration
E. Primary surgical reconstruction
immobilization of bony fragments

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 KAZANJIAN -PHASE APPROACH (MANGMENT)
 Recons plates
 MMF
 External pin fixation
 Archbar
 Splint
F. Closure of skin and mucosa
(local flaps-grafts)
G. Drainage (contaminated wounds)

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CONTAMINATION
• All gunshot wounds are contaminated
• Missile fragment, bullet, lodged in tissue leads to abscess
formation
• Intra-articular bullet fragments and bullet near to nerves
should removed
• Projectiles from gunshot are not sterile
• Prophylactic antibiotics plus tetanus prophylaxis indicated

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Radiopaque mass in the sinusRadiopaque mass in the sinus

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(KAZANJIAN -PHASE APPROACH
(MANGMENT)
 IMMIDIATE POST OP PHASE
Reassure sympathetic nursing
Special feeding device
Saliva shield
Mouth washes
Tracheostomy care

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KAZANJIAN -PHASE APPROACH (MANGMENT
 RECONSTRUCTIVE PHASE
First surgery reduce later reconstruction
Skin grafting (immediate)
Bone grafting
Mid face (immediate/primary reconstruction)
Mandible (late reconstruction) but mandibular segment
is maintained with plate
Teeth prosthesis (late)

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FUNCTIONAL RECONSTRUCTION
 Ridge augmentation
 Dental implants
 Scar revision

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GOALS OF RECONSTRUCTION
• Restoration of function
• Rebuilding of facial feature and improvement of
appearance
• Preparation of patient to re enter in society
• Improvement of psychodynamics

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EARLY RECONSTRUCTION
ADVANTAGES
 Early stabilization and support of soft tissue
 Decrease scar contracture
 No secondary surgery
 No long term facial deformity
DISADVANTAGES
 Infection
 Lack of tissue for proper covering
 Long operating time
 Loss of bone graft

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DELAYED RECONSTRUCTION
 ADVANTAGES
 Satisfactory result in appearance and function
 less chance of infection
 Implant can be placed
 Patient afford second surgery
 Decrease chance of failure of reconstruction
DISADVANTAGES
 Loss of facial deformity
 Scar revision

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GRAFT SOURCESGRAFT SOURCES
BONE GRAFT SOURCESBONE GRAFT SOURCES
RibsRibs
Illiac graftIlliac graft
fibulafibula
CalvariumCalvarium
Alloplastic bone materialAlloplastic bone material

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ASSESSMENT OF PATIENT FOR
RECONSTRUCTION
1. Hard tissue defect
 Radiographs for assessment of extent of defect
 Site of defect
 Size of defect
2.Position of residual fragments
3.Assessment of soft tissue bed

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DIFFERENT FLAPS
 Pedicle flaps
A. Local flaps
1. mucosal
2. skin
3. fats
B. Distant flaps
1. fasciocutaneous
2. myocutaneous
 Free flaps (totally removed

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SPECIALIZED SRUCTURE DAMAGE
1. Facial nerve (3-6%) GSW
a. Contaminated wounds repair delayed for 48-72 hrs
b. Repair should be made in initial surgical procedure.
c. should not be delayed more than a months
2. Salivary duct
a. Repaired or ligated (intravenuse catheter or
polymericsilicone tubing

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MANAGEMENT OF SALIVARY FISTULAE:
(A Classification of Reported Methods in the Literature)
1. Diversion of secretion into the mouth
A. Reconstructive methods
 Delayed primary repair of duct
 Reconstruction of duct with vein graft
 Mucosal flaps
 Suture of proximal duct to buccal mucosa

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B. Formation of a controlled internal fistula
 T-tube or catheter drainage into the mouth
 Drainage of proximal duct by a catheter
C. gland removal
D. Local therapy to the fistula
 Excision
 Cauterization

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2. Depression of secretion
A. Surgical approaches
 Duct ligation
 Sectioning of the auricotemporal or Jacobsen's nerve
B. Conservative approaches
 Administering nothing orally to the patient until the fistula closes
 Drugs: atropine or Pro-banthine
 Radiotherapy
 Repeated aspiration and pressure dressing

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PENETRATING NECK INJURIESPENETRATING NECK INJURIES
 GSW of the face may be associated with entrance andGSW of the face may be associated with entrance and
exit wound in the neck.exit wound in the neck.
 MONSANS Zones of the neck.MONSANS Zones of the neck.
Zone 1;area from clavicle to cricoidZone 1;area from clavicle to cricoid
cartilage (mortality 12 %)cartilage (mortality 12 %)
 ContentsContents
– A.A. carotid arteriescarotid arteries
– B.B. subclavian arteries and veinssubclavian arteries and veins
– C.C. internal jugular veinsinternal jugular veins
– D.D. thoracic duck, esophagusthoracic duck, esophagus
– E.E. thyroid gland, tracheathyroid gland, trachea
– F.F. brachiocephalic trunk etcbrachiocephalic trunk etc

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ZONE-2ZONE-2
 Area from cricoid cartilag to the angle of mandibleArea from cricoid cartilag to the angle of mandible
 ContentsContents
 Common carotid arteriesCommon carotid arteries
 Internal and external carotid arteriesInternal and external carotid arteries
 Internal jugular veinsInternal jugular veins
 LarynxLarynx
 Cranial nerves X, IXCranial nerves X, IX

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ZONE-3 (From Skull Base To TheZONE-3 (From Skull Base To The
Angle Of Mandible)Angle Of Mandible)
ContentsContents
– Carotid arteriesCarotid arteries
– Internal jugular veinsInternal jugular veins
– Cranial nervesCranial nerves
Mandibular fractures accompanied by injuries to zone-3Mandibular fractures accompanied by injuries to zone-3

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Airgun pellet deep to external carotid artery

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MANAGEMENT OF ZONE
PENETRATING NECK WOUNDS
• ATLS protocol for airway
• Primary survey
• Secondary survey (rule out hard sign of vascular
and laryngotracheal injury)

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MANAGEMENT OF ZONE
• Symptomatic patient
• Zone-1 perform angiography followed
by neck exploration
• Direct essophagoscopy vs
postoperative barium swallow

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• Zone-2 (symptomatic patient)
 Check hard signs
 Neck exploration
. Asymptomatic patient
 Advise computed tomographic angiography

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ZONE-3
• Perform angiography
•
• Perform interventional radiology
• Neck exploration

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CHYLE LEAK
MANAGEMENT
Intra-operative
Apply continues positive pressure
Ligation of thoracic duct
Sclerosing agent
post op
High output > 400-500cc/d
Re-exploration of neck
Trendelenburg’s position
Sclerosing agent

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Low output
Aspiration
Dressing
Diet of medium chain triglycerides

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THANKS……