Where a Trauma Surgeon Can Go Ballistic?
Michael E. Sugrue
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Introduction
The treatment of blunt trauma patients is the focus in the delivery of trauma care worldwide, particularly in Europe and Australasia. The probabilities and nature of injury in blunt mechanisms are very different when compared to penetrating mechanisms. This may challenge the trauma surgeon, espe- cially one who infrequently participates in the management of ballistic injuries. Optimum ballistic trauma care can be difficult to deliver due to the infrequent nature of the injuries seen. The trauma surgeon, while predom- inantly empowered to treat the blunt multi-system patient, needs to have a consistent and rational approach to the management of specific penetrat- ing injuries.
This chapter will deal with some of the issues that are faced by surgeons who otherwise have limited exposure to ballistic types of injuries. It will focus on some of the errors encountered and suggest a strategy to reduce these mistakes. A key to improving, overcoming, and reducing complica- tions, even in advanced mature trauma services, lies in providing safety and reducing errors.1
Prehospital Care
The outcome of trauma care is only as good as the weakest link. The first challenge we face as surgeons is to recognize that more than surgeons treat trauma patients and that a team approach is required.2
The trauma surgeon managing penetrating injury must ask: Is our pre- hospital system adequately prepared to deal with patients with penetrating trauma?
To be more specific, a number of key questions need to be answered:
– What is the communication system from the scene to the resuscitation room?
– What quality assurance and performance improvement mechanisms are in place with the ambulance and retrieval service?
– What are the errors that are going to be made by prehospital care providers?
A prehospital response for penetrating trauma should be significantly quicker or have a greater degree of urgency, in general, than for blunt trauma.
In an environment where blunt trauma is the predominant source of injury, a consistent and optimum approach to penetrating trauma may not be avail- able due to lack of appropriate guidelines. In addition, there may be a relative lack of experience in prehospital care providers due to the lack of exposure.
Errors in prehospital management of penetrating injury can result in pro- longed scene times, inappropriate fluid resuscitation, and poor prehospital to resuscitation room communication. It is hard to see any justification, outside a mass casualty situation, where there is a scene delay while the first ambulance waits for a more senior second responder to arrive and then take the patient to the hospital. This is not an uncommon scenario in Europe and Australia.
The definitive care of penetrating trauma should be based upon proba- bilities and decision-making.3 Information relating to the vital signs of a patient are crucial, especially in the presence of prehospital hypotension with a systolic blood pressure of less than 90 millimeters of Hg in a pene- trating trauma patient, as it invariably equates with the need for emergency surgery.3Emergency surgery will be required within the first hour of arrival in over half of these patients. Failure to obtain adequate information will put the surgeon at a significant disadvantage, potentially resulting in pro- longed times in the resuscitation room, poorer preparation, and longer times to definitive arrest of hemorrhage. Recent suggestions that each three-minute delay in the resuscitation room will result in an increase in mortality of approximately one percent in a patient with significant bleed- ing are a potent reminder of the importance of timely care.4
Occasionally, the prehospital information may not be precise or doubt exists as to whether the patient has been shot. Coupled with a lack of expo- sure in the emergency staff to penetrating injuries can result in missed or delayed diagnosis. Patients may also come by private transport, which can make prehospital information unreliable, as can be seen in the case of a young man being treated by the emergency registrar for herpes zoster after he told them he had blurred vision and spots, only to have a television- channel enquiry about a young male who was shot in the head (Figure S5-1). In societies where gunshot wounds are infrequent, it is not uncom- mon for patients to imagine that they may have been assaulted with a blunt instrument or deny that they have been shot, posing challenges for the emergency department triage. Very careful inspection will give an indica- tion that the patient has been shot rather than stabbed or hit with a blunt object, as seen in Figure S5-2. Telltale marks can include the jagged nature of the wound and the presence of burning or powder residue.
Figure S5-1. Patient who was being treat as herpes zoster.
Figure S5-2. Patient who was said he fell on a stick, but who chest X-ray showed a bullet in the upper mediastinum.
Challenges in Thoracic Trauma
For the “blunt” trauma surgeon dealing with gunshot wounds to the chest, the majority will have been inflicted with a low-velocity handgun. There are a number of key questions that will be faced:
– For lateral chest injuries, what is optimal management?
– Can I send the patient home after six hours?
– Is there pleural penetration and should I explore the chest with my finger?
– What is optimal management of injuries in the “box”?
– What is optimal management of a thoracoabdominal injury?
– What should I do with a transcervical or transmediastinal gunshot wound into the thoracic inlet?
– When should an emergency room thoracotomy versus an urgent operat- ing room thoracotomy be performed?
The infrequent exposure to specific scenarios makes decision-making difficult. While we are all fairly well versed with guidelines for the man- agement of blunt aortic injury and have had the opportunity of dealing with multiple scenarios, the challenge of penetrating trauma may not be as well informed.
Additionally, gunshot and shrapnel injuries to the lateral chest wall can pose a challenge for the blunt trauma surgeon.
– Do I debride?
– Do I resect?
– Does the patient need a chest tube for through-and-through injuries?
– Do these patients need other special investigations?
An example is shown in Figure S5-3 of a patient with shotgun injury to the left chest. The young lady was shot at about 4 meters with a shotgun.
Having sustained significant soft tissue injuries to her left breast and chest, the surgeon opted to perform a debridement, which amounted to almost a partial mastectomy. This was on the basis that there was some non- confluent areas of skin loss. This is probably unnecessary. There is a ten- dency for over resection of wounds following handgun and shotgun injuries by surgeons not familiar with ballistic injury. On the other hand, with infre- quently seen high-velocity injuries, there is often a reluctance to undertake aggressive debridement of devitalized tissue.
The principles of management of a lateral chest injury should be in keeping with Advanced Trauma Life Support (ATLS) and the Definitive Surgical Care Course principles.3
Figure S5-3. A shotgun injury to the anterior chest wall resulting in major debridement. (a) CXR showing shot gun pellets and underlying injury. (b) Post debridement.
a
b
Figure S5-4. Craniodigital reflex. The desire to stick a finger in every hole.
– There should be no digital probing of the penetrating lateral chest wound, as seen in Figure S5-4, as this will only induce a pneumothorax, cause bleeding, or introduce exogenous infection.
– A chest tube should be inserted in the presence of a hemothorax or a pneumothorax.
– Antibiotic coverage should be administered at the time of chest tube insertion.5
– A computed tomography (CT) scan of the chest may be helpful in deter- mining the missile trajectory and, if there is any doubt as to a possible cardiac injury, an echocardiogram or transesophageal echo should be per- formed. Detection of a septal defect in the presence of penetrating trauma, especially a stab wound, should not be attributed to a congeni- tal defect. Missed injuries must be avoided6 and assessment of the diaphragm should be undertaken where the entry point is in the region of the thoracic abdomen.This can be undertaken ideally with laparoscopy or alternatively with thoracoscopy. A CT scan of the abdomen or thorax is not as reliable for determining diaphragmatic injury.
With transmediastinal gunshot wounds, the indications for surgery follow basic principles of penetrating injury care; firstly, hemodynamic instability equals immediate operation. In the stable patient with injury to the bronchus, esophagus, major vessels or thoracic ducts, it is important that appropriate investigations are ordered to evaluate these structures. It is also important that these evaluations be undertaken in the first six hours of the
patients’ presentation to the hospital, not the following morning. Failure to detect an esophageal injury in the first twelve hours may result in mortal- ity or significant morbidity. Inability to primarily repair the esophagus will doom the patient to a staged esophageal repair and a complex protracted intensive care unit (ICU) and hospital course.
The initial management of patients who have sustained gunshot wound or penetrating shrapnel injury to the chest, sometimes coupled with a blast injury, will pose a challenge for the blunt trauma surgeon who, under normal circumstances, would rarely perform an emergency room thoracotomy (ERT). To psyche one’s self up from the usual of nonoperative management to an emergency room thoracotomy, while seemingly straightforward, can be psychologically challenging.
While the patient who arrives in the resuscitation room talking is very unlikely to need an emergency thoracotomy, a patient who is profoundly hypotensive with a penetrating chest injury needs an immediate ERT in the emergency department.
Further challenges facing the blunt trauma surgeon include the location of the incision, (often made too low); the type of incision (often not con- verted to a clamshell for rapid access to both sides of the chest), deciding which side to enter first (occasionally entering the wrong side), positioning of the equipment (incorrect positioning of the chest retractor as seen in Figure S5-5, with the bar across the center of the chest instead of laterally), attempting to cross-clamp the aorta first instead of checking for a pericar- dial tamponade and finally having a stepwise plan of action prior to inci- sion. Failing to make the right incision can pose challenges in terms of access, as shown in Figure S5-6. While this patient’s anterolateral thoraco- tomy has obviously resulted in the patients’ survival, the incision is too low and would be difficult to convert into a clamshell incision.
Challenges in the Abdomen
What could be less challenging than the abdomen, where the trauma surgeon is usually the king? In reality, decision-making and operative tech- nique has a major impact on outcomes. Key errors in ballistic trauma to the abdomen can be made in the following situations in particular:
– Failure to institute damage control principles in appropriate patients with major abdominal injury where technically brilliant surgery may directly contribute to the death of the patient because of the length of time required. The presence of hypothermia (<34°C), acidosis, and massive transfusion should prime the surgeon about the need to abbreviate any surgical procedure once the site of surgical bleeding has been controlled.
The patient in Figure S5-7 had a shotgun wound to the mid abdomen and demonstrated some classic provider-related errors with failure to perform
Figure S5-5. Incorrect positioning of chest retractors.
Figure S5-6. Thoracotomy incision is too low.
Figure S5-7. Shotgun injury to mid abdomen.
Figure S5-8. Transpelvic gunshot.
damage control surgery, proceeding instead to complex gastric surgery per- formed along with three small bowel resections and anastomoses over a four-hour period.7,8The patient died of exsanguination from coagulopathy in ICU two hours after surgery. He was profoundly hypothermic with a temperature of 32.8°C and a base excess of -12, having received 18 units of blood.
While this case was undertaken in the late 1980s, before damage control was popularized, it highlights the effect of inappropriate and prolonged surgery. Although this case was treated 15 years ago, for many surgeons damage control and the abdominal compartment syndrome still remain a mystery despite many recent advances.9,10
It is vital that surgeons do not delay transfer to the operating theater in a patient with obvious indication for laparotomy. In no situation should the patient be placed in a holding pattern, circulating in the radiology depart- ment between CT scanning and/or angiography while the surgeon organizes other commitments or displays indecision.
Failure to thoroughly evaluate the rectum for injury after a transpelvic gunshot wound (Figure S5-8) is a serious mistake. Failure to diagnose a pen-
Figure S5-9. Challenging gunshot wound to face.
etrating rectal injury at first laparotomy in a trans-abdominal, pelvic gunshot, or shrapnel injury will result in secondary peritonitis and a high mortality. The surgeon must also resist the temptation to suture shrapnel injuries to the buttock and perineum. These wounds should be examined under anesthesia, debrided appropriately, and left open.
Challenges in the Head and Neck
Rarely, if ever, do we operate in the neck in blunt trauma patients. Deci- sion-making and prioritization are very challenging with ballistic injuries to the head and neck, as seen in Figure S5-9. Obviously, the principles are somewhat similar, with attention to the airway, and in this particular case, a successful oral intubation was not secured and had to be followed by immediate cricothyroidotomy. With the increasing tendency towards non- operative management of penetrating neck injuries, there is almost some surgical guilt when undertaking surgery in this region. It is important for
the blunt trauma surgeon to reduce potential errors in judgment by avoid- ing sending patients of borderline hemodynamic stability with Zone 1 neck injuries to the radiology department. A patient with a major vascular injury at the root of the neck is a time bomb, and ideally, radiological procedures should be done in an operating room environment. While this is not possi- ble in most hospitals, facilities for urgent intervention should always be available; certainly, patients should not be transferred without a surgical presence to angiography. There are times when “cold steel” (size 10 or 20 scalpel) is preferable to “coiled steel”.
A transcervical gunshot wound poses many challenges, as often the path of the bullet may deflect, and in the stable patient without airway compro- mise, a CT scan may provide a useful trajectogram. It is important at the outset, especially with non-English speaking patients, to realize that gunshot wounds, especially handgun wounds to the neck, may present as apparent stab wounds.
Another challenge or pitfall in ballistic trauma is the high probability of through-and-through injuries. Figure S5-10 shows a young male who had arrested after arrival in emergency following an anterior abdominal stab- bing and went immediately to the operating room. At first, a medial visceral
Figure S5-10. View of the abdominal aorta following posterior surture (white arrow) during a medical visceral rotation. However, the anterior aortic injury was not inspected.
Figure S5-11. Potential pitfalls of an undiagnosed gunshot injury in patient who eventually died.
rotation was performed with a beautiful repair of the posterior aorta. One would think, to put it “bluntly,” that the surgeon would have thought of the anterior wall. Well . . . that was fixed the following day when there was persistent bleeding!
Challenges in Limb Trauma
Penetrating limb trauma, particularly lower limb trauma, can create some challenging decision-making and prioritization. This is particularly so when the patient does not have an obvious life-threatening injury. This is not the case in Figure S5-11, however, where an unfortunate male suffered a cardiac arrest in the emergency department after being brought in by ambulance from a nearby park. The patient was initially semiconscious, uncooperative, and arrested some fifteen minutes after arrival. During cardiopulmonary resuscitation (CPR), it was noted he had some blood through his trousers posteriorly, where eventually a bullet wound was found, and while he made it to the operating theater, he eventually died from multi-organ failure. At
post-mortem he was shown to have transected the profunda femoris artery.
This is a chilling reminder of the importance of thorough physical exami- nation and the challenges of secondary survey. It should always be remembered that tertiary surveys should supplement the initial secondary survey and help reduce delayed diagnosis of injuries.
In the emergency department, faced with a simple bullet wound and normal pulses, there is an overwhelming desire to digitally explore wounds.
This is an unnecessary evil in the majority of ballistic wounds to the limb.
Invariably, the wounds do not need to be excised, as there is little cavita- tion and necrosis of the skin. With the presence of pulses and a normal ankle/brachial index, with the exception of shotgun wounds or small shrapnel injury, there is little indication for further investigation. Care must be particularly exerted where there is swollen calf or pain out of proportion to signs, as a compartment syndrome may go undiagnosed. It should be remembered, however, that injuries in the region of vessels, even of small caliber, run the risk of developing pseudoaneurysms and arterio-venous fistulae. Shotgun injuries have the potential for bullet embolisation, and this is where decision-making and thought process need to change mode from management of blunt trauma to avoid making mis- takes. So if your young patient has been shot in the abdomen with a shotgun, the risk of embolisation distally must be considered, especially in the presence of dusky legs. Clinical examination supplemented by arterial dopplers and plain radiography will demonstrate emboli, as shown in Figure S5-12. Delay to theater would result in loss of limb, potentially loss of life. and even though fasciotomies are performed (as shown in Figure 12), this may be too late.
Conclusion
While the blunt and penetrating trauma surgeons are equally well trained, sharing in the skills of trauma and surgery, it is the decision-making and judgment that is paramount in penetrating trauma. The desire to stop the bleeding, the use of judicious investigations supplemented with cold steel and/or angiography for that urgent hemorrhage control, as well as with the principles of damage control, all of which essential components of care.
These principles of care are clearly dealt with in the Definitive Surgical Trauma Core Course.
Figure S5-12. Pellet emboli and subsequent delayed fasciotomy with eventual amputation.
References
1. Hoyt DB, Coimbra R, Potenza B, Doucet J, Fortlage D, Holingsworth-Fridlund P, Holbrook T. A twelve-year analysis of disease and provider complications on an organised level 1 trauma service: As good as it gets? J Trauma. 2003;54:26–27.
2. Sugrue M, Seger M, Kerridge R, Sloane D, Deane S. A prospective study of the performance of the trauma team leader. J Trauma. 1995;38(1):79–82.
3. Clarke JR, Trooskin SZ, Doshi PJ, Grenwald L, Mode CJ. Time to laparotomy for intraabdominal bleeding from trauma does not affect survival for delays up to 90 minutes J Trauma 2002, 52:420–425.
4. Sugrue M , Danne P, D’Amours SK. Definitive Surgical Trauma Care Course Manual. Sydney: University New South Wales; 2001.
5. Eastern Association Surgery Trauma. Available at: http://www.east.org/tpg.html.
Accessed June 6, 2003.
6. Janjua KJ, Sugrue M, Jones F, Deane SA, Bristow P, Hillman K. Prospective eval- uation of early missed injuries and the role of the tertiary trauma survey.
J Trauma. 1998;44;1000–1007.
7. Offner PJ, de Souza Al, Moore Ee. Avoidance of abdominal compartment syn- drome in damage control laparotomy after trauma. Arch Surg. 2001;136:
676–681.
8. Hoey BA, Schwab CW. Damage control surgery. Scand J Surg. 2002;91(1):
92–103.
9. Balogh Z, McKinley BA, Holcomb JB, Miller CC, Cocanour CS, Kosar RA, Valdivia A, Ware DN, Moore FA. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma. 2003;54:848–861.
10. Ivatury RR, Porter JM, Simon RJ. Intra-abdominal hypertension after life threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance of gastric mucosal pH and abdominal compartment syndrome.
J Trauma. 1988;44:1016–1023.
