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27 Ballistics inTrauma
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233
gastric tube) which will lessen artefactual marks on the bullet. This will help at the time of ballistic identication so as
not to obscure potential class or specic gun marks left on
the bullet. The bullet must be properly sealed, labelled and
dated with the site of retrieval indicated and names of treating physician specied. All bullets must be packed
separately.
27.1.2 External Ballistics
This describes the travel of the projectile outside of the barrel
through the air or a different medium, on its way to the target. Bullets are inherently unstable, as most of the mass lies
at the rear of the bullet. The bullet spirals because of the
riing of the barrel, and the instability can be characterised
as:
1. Yaw: Rocking from side to side.
Yawing represents deviation of the bullet in its longi-
tudinal axis, making the projectile unstable. As the bullet
travels, it may start to tumble.
2. Tumbling: The bullet tumbles in ight.
Tumbling represents forward rotation around the cen-
tre of the mass resulting in a greater surface area on
impact. The more unstable the bullet is, the greater the
tissue destruction.
3. Nutation and precision: The tip (leading edge of the bul-
let) rocks in a spiral fashion.
The bullet also has precision and nutation movements
along the horizontal axis.
The severity and extent of injuries resulting on the body at
point of impact depends on a number of factors which include:
1. The velocity of the bullet on impact and the velocity on
exit. The greater the retardation, the more energy has
been transferred.
2. The range from which the shot was red (bullets slow
down with distance).
A high-velocity round red from a longer distance
may result in a low-energy wound.
3. The type of missile or bullet used.
Bullets can be designed to mushroom or open on
impact to increase their cross-sectional area and therefore
retardation.
4. The area of the body hit (see Fig.27.2).
5. The number of bullets.
6. Whether there was any intermediary object in the way,
e.g. protection, car door, etc.
7. Whether the bullet was stable or unstable at time of impact:
Did it go straight through, was it tumbling, etc?
8. The presence of underlying natural pathology and state of
health.
27.1.3 Terminal Ballistics
The effect and movement of the bullets at point of impact is
referred to as terminal ballistics. If the track of the bullet is at
precisely 90 ° to the surface of the target (body), the bullet tip
may enter cleanly. However, if the bullet is tumbling, it presents a much greater surface area, with greater retardation of
velocity and transfer of greater energy to the tissue.
27.1.4 Wound Ballistics
The injuries that result from bullet wounds are known as
wound ballistics. This is the clinician’s actual point of care,
which can only be competently exercised if there is an understanding of the potential injuries, also based on the type of
weapon, the energy of the projectile and the nature of the
bullet itself. It is no longer appropriate to talk of ‘highvelocity’ and ‘low-velocity’ injury. Injuries are better classied into ‘high-energy injuries’ and ‘low-energy injuries’.
Fig. 27.2 Handgun bullet designed to open on impact and increase its
cross-sectional area, often used for self-defence
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Fig. 27.3 Cavitation in a high-energy bullet showing the shock wave
and temporary cavity
27.1.5 Cavitation
When a bullet travels through tissue, it is associated with a
shock wave in advance of the bullet. The shock wave drives
the tissues away from the bullet, resulting in a cavity which
has a high negative pressure. The movement is dynamic, and
behind the bullet, the cavity the vacuum created has the
effect of sucking external debris, clothing, etc., into the
wound. The shock wave travels furthest and fastest in dense
tissue such as the liver and brain, and least damage occurs in
air-lled cavities like the lung (Fig.27.3).
The nal tissue damage represents a combination of the
following features:
M. S. Moeng and K. D. Board
27.2.1 Thought Processes
• Always think trajectory: this will assist you in consider-
ing possible tissues and organs that may have been damaged by the bullet. While bullets do not always travel in
straight lines, unless they hit a tissue like the bone, the
path between the bullet markers will provide a good
guide.
• Always use bullet wound markers: a simple paper clip
attached to wounds will assist you in interpreting the trajectory with assistance of basic radiology (develop a system in your unit for anterior vs posterior wounds, e.g.
open paper clips for the former and closed paper clips for
the latter). Vitamin E tablets can also be used. Do not use
ECG ‘dot’ as these may be confused with bullet fragments (Fig.27.4).
• Always count the number of bullet wounds. Wounds will
generally be even numbered if the bullet has passed
through (i.e. an entrance and an exit). A single or odd
number of wounds implies a retained bullet (Fig.27.5).
• The permanent cavitation from the bullet as it tracks
through the tissues.
• The temporary cavitation by the shock wave effect of the
bullet especially present in high-energy missiles. This
will cause damage further away from the direct path of
the bullet. It may also suck in bacteria and other surrounding foreign material into the deeper tissues.
• Note that because the cavity is temporary, it is not seen
clinically, and the amount of soft tissue damage is commonly underappreciated.
• Impact of secondary fragment such as bone, glass and
break-up of the missile itself.
27.2 Initial Management ofGunshot
Wounds
All normal principles of major trauma management apply,
using ATLS® principles.
Fig. 27.4 Chest X-ray showing the use of bullet markers (paper
clips)—high suspicion of liver injury
ab
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235
Unless there is one GSW (gunshot wound) and a single
retained bullet, you must refrain from clinically committing to an entrance versus an exit wound. Rather, describe
the wounds without labelling them as entrance and exit
wounds.
Fig. 27.5 Multiple gunshot wounds
• Always obtain X-rays based on the above ‘hole count’,
and if there is a ‘mismatch’ between holes and bullets,
X-ray the whole body as widely as necessary to exclude
remote injury.
• Have a high index of suspicion for ‘silent’ associated
injuries, e.g. GSW involving the anterior portion of the
thoracic or cervical spine must imply oesophageal injury
till proven otherwise.
• Plain X-rays are most accurate for identifying missile
debris.
• CT scans may miss small pellets or fragments unless very
ne cuts are used. CT scans should be used in haemodynamically stable patients only.
• Deal with the wound and not the type of rearm used
(Fig.27.6a, b).
27.2.2 Shotgun Injury
A shotgun res multiple balls, 2–4mm in diameter. These
are contained in a plastic cup inside the shotgun round. The
shotgun has a smooth barrel, and the effect is that the pellets
spread out, hitting a much larger area of the torso. Most balls,
Fig. 27.6 (a) Abdominal gunshot with omentum protruding. (b) Underlying bowel injury
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Fig. 27.7 Shotgun cartridge showing plastic insert containing pellets
and one removed from a victim
if they penetrate, will stop inside the body. The plastic ‘wadding’ which drives the pellets is radiolucent and must be
looked for and removed (Fig.27.7).
Ultrasound location may be helpful. Retained wads are a
signicant source of sepsis.
• Do not remove individual pellets unless they are in close
proximity to a vital structure. There is a greater likelihood
of surgical damage to overlying normal tissue when trying to nd the pellet.
• Holes in the bowel can be oversewn.
• Always X-ray the entire body. An ectopic pellet may have
embolised remotely. The hole in the blood vessel for it to
get there must be anticipated and repaired.
• Always look for the plastic cup/wad, which is radiolucent.
A>1cm round hole on the skin is highly suggestive of its
presence. It should be looked for and removed.
• Shotgun injuries of the abdomen with multiple holes in
the bowel require a methodical approach. All bleeding
vessels should be ligated. All bowel holes should be
closed primarily. Treat such injuries as requiring a mandatory relook laparotomy, since it is extremely easy to miss
M. S. Moeng and K. D. Board
holes, and relooking is helpful. Pass the bowel through a
bowl lled with warm water. Bubbles are highly suggestive of a perforation of the bowel.
• A relook laparotomy at about 24–36h, with reinspection
of the bowel, is very useful as extra holes may be picked
up.
27.3 Denitive Care
• Low-energy wounds can be cleaned in the absence of
injury to vital structures.
• Use copious wound irrigation with warmed lactated
Ringer’s solution
• Except for the face, do not suture bullet wounds of the
skin. Simply trim skin tags and use a local dressing with
an antibiotic ointment, e.g. chloramphenicol or bacitracin. The wound should be dressed, but will drain uid,
rather than develop a retained haematoma.
• In stable patients, the small bowel can be closed primarily. Large bowel injuries can be closed primarily if less
than 6h old and with limited contamination. Protective
stomas are not usually necessary. However, in the unstable patient, principles of damage control apply.
• For solid organs, haemostasis with simple packing and
limited resection may be all that is required. Spleen and
kidney injuries may be most safely treated with splenectomy or nephrectomy.
• High-energy wounds require extensive debridement to
remove dead tissue. Where necessary, principles of damage control apply.
• Have an extremely high index for compartment syndrome
in abdominal and extremity wounds. Early or prophylactic decompression with a fasciotomy should be
performed.
• Antibiotic prophylaxis and wound care are required to
minimise the risk of infection. Gram-positive cover, especially for Clostridium sp., Staphylococcus and microaerophilic Streptococcus may be required. A penicillin or
cephalosporin is commonly used (Fig.27.8).
27.3.1 Removal ofBullets
The decision to remove a bullet should be balanced with the
risks of the procedure. The fear of lead poisoning due to bullets left in situ is not a major clinical problem.
Bullets that are clinically palpable, are in close proximity
to major vessels or nerves or are lodged in major joints
should be removed as they impact on quality of life.
27 Ballistics inTrauma
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Fig. 27.8 Liver injury showing typical stellate appearance from shock
wave
27.4 Forensic Considerations
Forensic evidence needed is by the police, irrespective of
whether the patient survives or dies. The correct handling
and bagging of bullets, or fragments, will ensure a chain of
custody that is accurate and dependable for the courts to be
able to use the evidence with condence. It is therefore critical to hand over and document to whom the bullet was
handed over, and this should be maintained and conrmed
until the ballistic tests are done.
Gunshot wound appearances of entrance and exit gunshot
wounds are for the most part different. The gunshot wounds of
entrance are typically round to oval, have a collar of abrasion and
may show close proximity gunshot residue (see Fig.27.4). The
sizes of the entrance wounds tend to be smaller than the exit
gunshot wounds; unfortunately, this is not always true (Fig.27.9).
Do not attempt to ‘second-guess’ the forensic pathologist.
The precise number and nature of the wounds should be
documented and, if possible, photographed. It is often not
possible, particularly with lower-energy wounds, to say with
certainty, whether a wound is an entrance wound or an exit
wound. This should be left to experts in the eld.
Remember that there may be gunshot residue on the
clothes, hands or body of the patient. The residue is what
comes out of the barrel with the bullet. It comprises ames,
soot, burnt and unburnt propellant, primer and oil. All relevant clothing should be handed over to the police or forensics for further evaluation.
27.5 Conclusion
Firearm injuries may cause complex injuries. Appreciating
ballistics offers a grounded approach to the management of
these cases. An unstable patient may be managed on clinical
237
Fig. 27.9 Oval-shaped entrance wound showing central defect and
collar of abrasion
suspicion of the suspected trajectory and basic radiology if
time permits. Even in emergency cases, a focused assessment may guide with surgical approach in theatre. More
elaborate examination should be ordered in stable patients as
the suspected injuries permit. Match the wound with the bullet and expect an even number unless the wound is obviously
tangential. Treat the wound and the injuries and not the rearm involved.
Important Points
• Bullets do not always travel in straight lines; they can
ricochet off the bone.
• Always use skin markers. If the injuries are not in a relatively straight line, or is there a bone chip in the tract, has
the bullet ricocheted off a piece of bone, e.g. a vertebral
body?
• Bullets do not always stay intact. They can break up, and
each part can cause separate injury.
• Previous retained bullets may confuse the current clinical
presentations.
• Failure to examine the perineum and the axilla may add to
the confusion in clinical interpretation.
• Mismatching wounds when dealing with multiple GSW
may lead to missed injuries (see Fig.27.5).
• Failure to remove slug/wad in close-range shotgun
injuries.
• Failure to debride the exit wound especially when bullet
has perforated hollow viscus especially the large bowel
and rectum.
• Failure to appreciate shock wave effect on surrounding
structures with tissue damage The author has seen a
splenic rupture from an iliac arterial injury, with the shock
wave transmitted up to the spleen via the aorta and splenic
artery.
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M. S. Moeng and K. D. Board
Suggested Reading
Boffard KD.Denitive Surgical Trauma Care (DSTC) manual. 5th ed.
Boca Raton, FL: CRC Press; 2019.
Breeze J, Allonson-Bailey L, Hunter N, etal. Mortality and morbidity
from combat neck injury. J Trauma. 2012;72:969–74.
Carr B, Schwab CW, Branas C.Outcomes related to the number and ana-
tomic placement of gunshot wounds. J Trauma. 2008;64:197–203.
Glasgow S, Stee S, Duncan S, Rusmussen T.Epidemiology of modern
battleeld colorectal trauma: a review of 977 coalition casualties. J
Trauma Acute Care Surg. 2012;73:S503–8.
Mahoney PF, Ryan JM, Brooks AJ, Schwab CW, editors. Ballistic
Trauma: A Practical Guide. 2nd ed. London: Springer-Verlag; 2005.
Velmahos G, Contantinou C, Brown C, et al. Abdominal computed
tomographic scan for patients with gunshot wounds to the abdomen
selected for nonoperative management. J Trauma. 2005;59:1155–61.
Part II
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Surgical Strategies in Penetrating Trauma to Head,
Face, and Neck
Surgical Strategies inTrauma
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TobyP.Keeney-Bonthrone, RachelM.Russo, JessieM.Ho,
andHasanB.Alam
28
In the United States, penetrating trauma remains a nationwide burden with the incidence of patients with penetrating
injuries rising in nearly every state. As many as 54% of
severely injured patients are initially managed at a nontrauma center, with many examples of patients with penetrating trauma self-presenting following episodes of mass
violence. The outcome for these patients can be inuenced
by providers that know what to do and hospitals that are prepared. Prompt control of bleeding and intra-abdominal contamination combined with goal-directed resuscitation
reduces morbidity and mortality. Because every minute
saved between time of injury and incision in the operating
room (OR) gives the surgical team additional time to nd
and repair any injury, optimal surgical strategies for penetrating trauma start prior to incision. This chapter will outline
the surgical strategies in trauma, starting with proper preparation and will highlight common errors and inefciencies
that can delay appropriate care.
We will focus on the following steps of surgical strategies
in trauma:
1. Preparation for trauma activations
2. Avoiding pitfalls in the initial assessment
3. Initial resuscitation strategies
4. Choosing damage control surgery vs. denitive repair
5. Keys to performing damage control surgery
6. Future advances in surgical strategies in trauma
T. P. Keeney-Bonthrone (*)
Department of Surgery, Northwestern University,
Evanston, IL, USA
Department of Emergency Medicine, Northwestern University,
Evanston, IL, USA
e-mail: dhc@ohsu.edu
R. M. Russo
Department of Surgery, University of California, Davis, CA, USA
J. W. Ho · H. B. Alam
Department of Surgery, Northwestern University,
Evanston, IL, USA
e-mail: hasan.alam@nm.org
28.1 Preparation forTrauma Activations
Optimal care of the penetrating trauma patient requires
numerous resources across the trauma system, incorporating
prehospital personnel, emergency department personnel, and
an array of multidisciplinary inpatient providers. However,
the initial stabilization of an injured patient can be accomplished at any-sized facility. In large centers, a trauma team
may encompass numerous specialists and subspecialists.
Removing extraneous personnel from the resuscitation bay
may be necessary to control crowds and manage noise. In
rural hospitals in contrast, a trauma team may consist of one
physician and one nurse who might enlist the help of ancillary personnel to manage critically ill or multiple patients.
Regardless of the setting, effective and efcient communi-
cation and teamwork among clinicians and staff is essential to
deliver the best care. A trauma team must have a clearly designated leader who determines the management plan, priorities, and task assignments. When possible, the team leader
should avoid performing procedures, in order to maintain
situational awareness and focus on supervisory responsibilities as the patient’s condition evolves. A pre- brieng is helpful to delineate roles and ensure the availability of essential
resources (e.g., blood, sedation, procedural supplies).
Breakdown in team dynamics and medical mismanagement
typically results from one of four common problems:
1. Communication breakdown—a lack of closed-loop com-
munication results in ineffective communication between
the team leader and those providing bedside care. The
priority of tasks is not conveyed.
2. Failure of situational awareness—the team leader fails to
recognize shock and anticipate blood transfusion needs or
delays the initiation of patient transfer.
3. Inadequate stafng or problems with workload distribu-
tion—bedside providers become task-saturated by
numerous to-dos with no clear prioritization of tasks or
an inadequate number of staff for the task load/patient
volume. Staff are inadequately trained to perform the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_28
241
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T. P. Keeney-Bonthrone et al.
assigned task or have not maintained infrequently used
skills.
4. Unresolved conicts—interpersonal conict, disagreement about management, a lack of clear leadership, or
unresolved hostility about other team members’ perceived inadequate performance.
Avoiding these common problems in patient care requires
improvement in team dynamics that can only come with
rehearsal and reection. While large, level 1 trauma centers
may be well-versed in trauma activations for penetrating
injury, many hospitals experience a much lower volume of
penetrating trauma and are focused on maintaining basic
competencies for trauma care. For these centers, preparation
is paramount since care teams cannot rely on extensive
experience to improvise care in unexpected situations. This
preparation occurs both at the organizational and at the individual level. All stakeholders across multiple departments
(e.g., surgery, anesthesia, emergency department) and support functions (e.g., operating room, radiology, blood bank,
pharmacy) should participate in the formation of plans,
tabletop exercises, and/or simulations. Improving operational workow ensures that patients receive the resuscitative and operative interventions they require in the timeliest
manner. Specic examples of organizational-level processes
that can be examined for workow optimization can be
found in Table28.1.
While the focus of institutional level improvement is efcient movement of the patient through the system, the focus
of individual level improvement is in fostering staff excellence during any steps that can cause friction. Areas of interest include seemingly simple procedures that can bog down
patient care such as IV placement in unstable patients, complex nursing procedures such as massive transfusion, as well
as multidisciplinary skills-based efforts such as OR preparation and preparing patients for interfacility transfer.
Signicant treatment delays may result if these tasks are
executed inefciently. An example of a procedure that can be
targeted for optimization can be found in Fig.28.1.
Working routinely with surgical and nonsurgical colleagues to rehearse trauma scenarios can optimize trauma
care even in environments where penetrating trauma is relatively rare. The hallmarks of a good trauma surgeon are welldeveloped leadership skills executed under pressure. Such
leadership takes time to develop, and these skills may not be
part of routine general surgery training. Practice is essential.
Errors and inefciencies are bound to happen, so a healthy
after-action review culture that focuses on opportunities for
future process improvements is essential. Some benecial
courses are offered to help hone these skills, including the
internationally offered Denitive Surgical Trauma Care
(DSTC) and Denitive Anesthesia Trauma Care (DATC)
courses run by the International Association for Trauma
Surgery and Intensive Care.
Table 28.1 Key aspects of trauma patient workow
Setting Stakeholders involved
Consistent radio communication of key decision- making parameters by
EMS to ED
Consistent, timely paging of all applicable non-ED staff when trauma
activation occurs
Timely mass casualty activation procedures with up-to-date rosters Hospital ED, hospital administration, trauma
Standardized handoffs by EMS to ED Trauma bay EMS, ED, trauma
Clear trauma activation responsibilities that account for frequent staff
turnover due to shift/call changes
Clear chain of command when expected attending(s) are unavailable
(e.g., still in OR due to previous trauma activation)
Optimizing trauma OR turnaround OR OR administration, OR staff, anesthesia,
Clear backup OR and “backup for backup” OR procedures as well as
external transfer processes for mass casualty situations
Optimizing transportation routes to OR Hospital OR administration, patient transportation
Sufcient, well-stocked surgical trays OR OR administration, OR staff, trauma
Intraoperative communication OR OR staff, anesthesia, trauma
Primary-to-consultant comms in OR OR Trauma, consultants (esp. orthopedics,
Optimizing transportation routes to IR suite OR OR administration, IR management, patient
OR turnaround time OR OR administration, OR staff
SICU handoff procedures SICU Trauma, SICU
Reoperation procedures for SICU patients SICU/OR OR administration, OR front desk, SICU,
Family-centered rounds for unresponsive/sedated patients to encourage
realistic decision-making
Prehospital EMS, ED, trauma
ED ED, trauma
Trauma bay ED, trauma, OR front desk
Trauma bay ED, trauma
trauma
OR OR administration, OR staff, hospital
administration, anesthesia, trauma
neurosurgery, IR, urology)
transportation
trauma
SICU Trauma, SICU
28 Surgical Strategies inTrauma
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243
Patient deemed
unstable on ED arrival
Place bilateral
16ga IVs in
antecubital
fossa
If 2 failed
attempts or
no access
within 90
seconds
Place bilateral
IOs in
humeral head
Place central line
in SICU/OR
Fig. 28.1 Simplied access algorithm for unstable penetrating trauma
patients
Successful
PIV
placement
x2
28.2 Avoiding Pitfalls intheInitial
Assessment
Prior to patient arrival, whenever possible, emergency medical services (EMS) should notify the receiving hospital that
a trauma patient is en route. Included information regarding
the patient’s estimated age, sex, mechanism of injury, and
vital signs should be standardized because it can aid in preparation for the patient’s arrival. Trauma responders should be
notied to ensure adequate resources are available and an
operating room can be readied quickly if needed. Emergency
department staff should prepare for additional procedures
(e.g., intubation, tube thoracostomy), and nursing staff
should work with the blood bank to prepare for massive
transfusion of uncross-matched type O blood. All staff
should follow universal precautions against blood-borne and
respiratory-borne illnesses.
A clear and organized approach is required for managing the patient with penetrating injury. Advanced Trauma
Life Support (ATLS) provides an outline for a standard
approach to trauma care that has been adopted around the
world. The initial patient assessment is divided into the
primary and secondary survey. The primary survey is
designed to quickly identify life-threatening injuries and
provide immediate life- saving interventions. The AirwayBreathing-Circulation mnemonic simplies priorities and
keeps the trauma team focused on a systematic approach to
patient care. However, since uncontrolled hemorrhage is
the leading cause of preventable deaths from traumatic
injuries, some have suggested the mnemonic be altered to
Circulation-Airway-Breathing to reect hemorrhage control as the number one priority. In many centers with multiple capable clinicians present, the team will be able to
concurrently address these problems. The secondary survey includes a detailed history and physical (when the
patient’s condition permits) and targeted diagnostic studies to detect other injuries. Patients with penetrating injury
most commonly receive a chest X-ray and abdominal
X-ray to identify injuries and missiles. Ultrasound may
also be helpful for patients with suspected cardiac injury
or pneumothorax. More details regarding the use of imaging for patients with penetrating injury can be found in
Chaps. 17, 18, and 19.
Clinicians at hospitals with limited resources for trauma
management should contact the nearest trauma center for
transfer as soon as it becomes apparent that a patient has
sustained injuries beyond the management capacity of their
hospital. While a thorough evaluation and initial stabilization
in accordance with ATLS principles is desired prior to
transfer, it cannot be overemphasized that transfer should not
be delayed to obtain a complete workup.
Pitfalls in the initial assessment:
Airway: Dened intubation criteria in trauma do not
exist. In general, it is wise to intubate patients early, prior to
the onset of respiratory failure. Intubation is often considered when patients present with severe brain injury with a
GCS less than 8, injuries to the face and neck that may lead
to airway obstruction from signicant edema, those with
severe pulmonary contusion at risk for hypoxic respiratory
failure, hemodynamically unstable patients, and patients
who may require signicant pain management or sedation to
facilitate further workup or interfacility transfer. There is not
a rush to intubate patients that are otherwise able to maintain
a patent airway with adequate oxygenation and ventilation
using other means. Esophageal or right mainstem intubation
is common during emergency intubation. Always verify tube
position with capnography and secure endotracheal tubes
once in position. Unintended extubation is the most common
preventable cause of morbidity in trauma patients in mature
trauma centers. Cardiovascular collapse on induction is
another signicant risk in this patient population. Ensure
adequate resuscitation prior to rapid sequence induction, and
use short-acting, non-vasodilatory drugs such as etomidate
or ketamine paired with succinylcholine or rocuronium.
More information on intubation of patients with penetrating
trauma can be found in Chap. 2.
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