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Fig. 63.4 Patient No. 3:
30-year-old female, who
sustained a solitary GSW to
the back of her head from
close range. Entry wound on
the occiput and no exit
wound. Plates a and b: Scout
images A/P and lateral with
evidence of a lodged bullet in
the L cerebellum behind the L
mastoid. Plates c:
preoperative image (bone
window) demonstrating L
p-fossa bullet. Plates d and e:
axial views of signicant
SAH, L infratentorial epidural
hematoma and CPAintraparenchymal hematoma
with pneumocephalus. Plates
f and g: axial views of
postoperative results status
post-suboccipital craniectomy
for decompression and
evacuation of hematoma with
some residual air in the
operative bed. Plates h:
supratentorial placement of an
R EVD for CSF diversion.
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f
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c
d
Fig. 63.5 Patient No. 4: 26-year-old male, who sustained a solitary
GSW to the head from distant range. Entry wound at the R ear canal, no
exit wound. Plates a and b: Scout images A/P and lateral with evidence
of multiple bullet fragments on the R extra-cranially and bilaterally
intra-cranially. Note the large R sided skull fracture. Plates c and d:
preoperative images (axial and coronal bone windows) demonstrating
R inferotemporal blowout skull fracture and skull base fracture from
middle cranial fossa entry point and steep trajectory with bullet remnants in the L frontal area. Plate e: axial view of R SAH and temporal
intraparenchymal hematoma, contusions, and artifacts from bullet fragments with pneumocephalus. Plates f and g: axial and coronal views of
postoperative results status post R hemicraniectomy for evacuation of
hematoma and status post-clipping of R sided MCA branches from
avulsion injury. Plates h: postoperative CTA with adequate perfusion
to the superior branches of the MCA, 2 aneurysm clips at the MCA, and
artifact from bullet fragments. Plates i and j: supratentorial views status post hemicraniectomy and small L frontal hematoma along the bullet tract.
gh
ij
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Fig. 63.5 (continued)
63.2 Preoperative andIntraoperative
For most TBI strategies, you will nd very little class 1 or 2
recommendations since one can often not randomize patients
in critically ill settings in a timely fashion, since it often
poses an ethical dilemma to delay treatment for study purposes. To get a good grip on how to run these scenarios and
how to treat your patient well, watch as many cases as you
can during training. Take home the pivotal steps of decisionmaking from seasoned staff. Remember the following points
to increase the possibility of a satisfying discharge-status of
a patient injured by gunshot or a stab wound:
full system review in the bay and type and cross blood
ASAP; get the patient lined up (two peripheral 16G IVs)
and treat abnormal vital signs (e.g., hypotension, hypoxia/
hypothermia!) before you move to the radiological examinations and before considering any surgical intervention.
Management
In all trauma patients, let the trauma team perform their
The minutes spent here are WELL SPENT and make your
later steps SAVE.No one wants to rush the GSW patient to
the scanner and see them crashing there. And remember:
NO GSW TO THE HEAD goes to the OR without lms
EVER! Have one team member assigned as liaison to the
relatives if you do not have the time to communicate during
the need of swift action. They will be extremely grateful and
less anxious. Once you have obtained your scans, make a
swift decision: Patients with a GCS of 3–5 AND a devastating scan (bilateral global injury with transventricular bullet
trajectory, massive blood or swelling with near complete
herniation, tramtrack signs) may not be salvageable and
warrant conservative treatment alone with/without ICP-bolt
placement and with medical management only. Other
patients with either improved post-resuscitation GCS > 5
and limited supratentorial injury and a vector that does not
show involvement of the fatal zone should be considered for
surgery.
NOW TO KEY POINTS OF THE INTERVENTION:
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63.3 Operative Management
Always ask yourself: “How can I do the best intervention the
fastest possible way”?
Here are the 15 most important points on the road to
success:
1. Transport the patient yourself from the CT scanner
straight to the OR.
2. Position the patient by transferring him from the stretcher
onto the OR bed (which should be placed correctly in the
room since you called from the CT scanner about the
procedure to be performed).
3. Apply only the utmost necessary padding to save time
(this is not the time to search for pneumoboots or extra
gel rolls).
4. Pin the patient in a Mayeld headrest at straight angles!
(Either supine or fully lateral or straight prone). This
will help to keep your orientation once you are deep
inside.
5. Shave the entire hemiconvexity (be generous!). Do not
try to make it look “pretty”.
6. Mark/scratch the skin to keep landmarks and pay attention to especially the midline!
7. Use a quick prep-solution: e.g., soaking beta-iodine
sponges followed by Prevail®; this is not the time to go
through six sponges of your three-soap elective
crani-routine!
8. Do not waste the time waiting for local anesthesia/epinephrine for better hemostasis.
9. Incise with condence and with the goal of creating a
generous ap (hemicraniectomy) to facilitate good space
for post-OP swelling.
10. Perform a generously sized hemicraniectomy for optimal decompression and do not forget to also prepare a
Frazier bur-hole in all p-fossa lesions so you can place
an external ventricular drain (EVD) any time.
11. Save the bone ap on the back-table to be used in a
freezer-storage protocol and do not waste time on a second (abdominal) incision! You want to get out of the OR
ASAP.
12. Always irrigate copiously with antibiotic solution: e.g.,
bacitracin®.
13. Perform your wide durotomy BEFORE you place any
dural tenting stitches since this decompresses the brain
earlier and you save the brain some more vital minutes.
14. Close the dura provisionally, e.g., with an onlay dural
allograft (e.g., duragen®) to prevent adhesions carrying
over from the bruised brain surface to the undersurface
of the muscle ap. A subgaleal CSF-oma is of no concern here, since you will be back for sure to do a regular
cranioplasty.
15. Close the muscle ap in three layers only to save some
time: (1) muscle + fascia, (2) galea, (3) skin.
Do not forget to talk to “your team” at all times during
the case and announce you next moves clearly and loud.
These are fast and stressful cases and performed not for
pretty but effective surgery; describe technical details that
make a difference (e.g., Anesthesia needs to know when
you open the dura to anticipate a change in ICP and SBP
response).
63.4 Perioperative Management
63.4.1 Cerebral Perfusion Threshold
An adequate cerebral perfusion pressure (CPP) is instrumental to keep brain tissue alive. Higher values are better here.
The goal value is the result of subtracting the ICP from the
mean arterial pressure (MAP). You may guess via the SBP if
your monitor does not calculate and display MAPs.
The critical cerebral perfusion pressure (CPP) threshold
for ischemia lies around 50–60 mmHg; do not overresuscitate with IV uids and DO NOT USE uids with concentrations of half normal saline (0.45%), which act as
hyposomolar volume expanders and may create signicant
brain edema. Remember: There is poor outcome in patients
with systemic hypotension, but there is risk of adult respiratory distress syndrome with too ambitious use of uids. So,
keep ICP low and MAP high enough with hypertonic saline
(ideally: 23%, given in 3 injections of 10 cc each over a
period of 3–5min. Into a central line) or use mannitol (e.g.,
1–1.5g/kg body weight is about 100g I/V for an average
sized person of 70kg). Do not hesitate to use pressors early
(e.g., Neosynephrine) and do NOT bring down systolic blood
pressure (SBP) if a patient comes into the ER at 165 before
you have a CT scan; he may need that pressure for good
perfusion!
Always monitor blood pressure (BP) frequently
(q2–5 min) and avoid systolic drops of BP <90 mmHg.
Now a personal hint which may raise a discussion point: Do
NOT waste time placing an A-line before CT scanning in
isolated head injuries. In a hemodynamically stable patient,
you are better off seeing the intracranial damage early and go
to the OR quicker rather than waiting 5min for line placement before you can make an informed decision. The OR
can work more efciently with teams acting in parallel,
which saves you vital minutes (needless to say: In the unstable patient, this does not hold true). Often, patients can have
a line placed in the trauma bay—but that does not always
work and does not justify a 15min delay for several people
trying!
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63.5 Intracranial Pressure Monitoring
Aim to always maintain adequate cerebral perfusion to prevent secondary damage! I still advocate for monitoring ICP
in all necessary settings of severe traumatic brain injury with
GCS<8 to dene the need of intervention (level II evidence).
However, what does that mean here? You are not able to
manage CPP correctly without measuring ICP and MAP!
However, if the patient goes to the OR anyway, do not waste
time placing an ICP-bolt monitor or external ventricular
drain upfront. It is more suitable for the post-OP setting. An
EVD is always preferred, since it allows not only to measure
the ICP but also for therapeutic CSF drainage.
Especially in smaller institutions, the threshold for invasive monitoring remains too high. Here we advocate a low
threshold for transferring the patient to an experienced center
and correct placement in an ICU setting. CT scans are not
appropriate for “guessing” ICP, but good enough pre-OP to
make a decision. If the patients scan supports non-operative
management in the setting of a low GCS or KPS, patients
should have an ICP-bolt placed ASAP.
By the way, if a CT does not present any abnormalities to
explain a low admission GCS, then we measure ICP when
two or more of the following features are noted: negative tox
screen, adequate oxygenation, patients above 40 years of
age, systolic BP< 90 mmHg, or the patient shows sign of
posturing (uni- or bilateral) (level III evidence).
Do not treat potentially high ICP for any prolonged period
of time prophylactically without correctly monitoring in the
ICU setting. This is NOT true for a sudden change in mental
status in a critically ill TBI patient; if you notice a rapid decline
in neurological examination, you SHOULD initiate therapy
immediately with hyperventilation and elevation of HOB to
30 degrees, mannitol or hypertonics and then go to the scanner
ASAP to explore the intracranial situation! Once again: “time
is brain” and lowering elevated ICP values for several minutes
can save a lot of tissue if used in the correct setting. Whether
you use a parenchymal or ventricular ICP- bolt- device is more
a question of preference than of evidence. However, the latter
is known for lower costs and offers the chance to also treat by
draining off excess cerebrospinal uid (CSF). Start treatment
if ICP is sustained >20mmHg (level II) for >5min and follow
respective clinical and radiological ndings.
63.6 Hyperosmolar Therapy
andBarbiturates
Mannitol or hypertonic saline are suitable to lower ICP and
may thereby increase CPP, thus improving perfusion and neurological outcome. As a rule of thumb, use mannitol at 1g/kg
body weight as a loading dose (level II). Equimolar doses of
NaCl may be given according to institutional protocols. Then
maintain the dosing but divide it into equal fractions (e.g., 25g
mannitol q6 h). Do NOT forget to also order holding parameters (e.g., hold next dose for Osm>320 or Na>155) to prevent drying the patient out. Also be aware that you might cause
transient arterial hypotension! Mannitol outweighs barbiturates in improving ICP, but bears a higher risk of hypotension.
While mannitol may have a detrimental effect on mortality
when compared to hypertonic saline, recent comprehensive
literature review found conicting evidence. Prophylactic
administration without evidence of increased ICP is not recommended. Only use barbiturates if ICP cannot be decreased
by any other measure to prophylactically slow metabolism. (It
also makes brain death determination really difcult.)
63.7 Hyperventilation andSteroids
Hyperventilation can reduce ICP. The mechanism most
likely comes from intravasal volume reduction secondary to
vasoconstriction. The method works well for 6h (giving you
a good time window to initiate further treatments) but can
turn detrimental thereafter. So do not use it without careful
consideration and limits! Avoid to excessive a protocol and
do not hyperventilate to a PaCO2<25mmHg during the rst
24h after TBI when cerebral blood ow (CBF) is often critically reduced (level II). Mind you that the day after a signicant injury, CBF is reduced to less 50% of normal individuals;
this means that you risk decreasing CBF even further with
aggressive hyperventilation and any subsequent reduction in
CBF may actually worsen the situation to the point that the
patient may become ischemic or stroke.
Do NOT apply steroids. Currently, there is no proven benet
for the prolonged use of systemic steroids in traumatic closed
head/brain injury and morbidity is known to increase in this setting. Earlier data had reported some benet, but this comes at an
increased risk for overall morbidity (e.g., infections, sepsis, and
pneumonia) especially in the population of elderly patients.
63.8 Infection Prophylaxis
Most general guidelines (level II) suggest periprocedural
administration of antibiotics to reduce the incidence of pneumonia after intubation in the patients with signicantly
decreased mental status.
Although gunshots are often considered to be sterile in
themselves, we support the notion of a 48–72-h period of
broad-spectrum antibiotic prophylaxis for prevention of meningitis secondary to a CSF leak with a dirty wound.
Vancomycin 1 g Q12 h and Gentamycin 80mg Q 8 h and
Flagyl 500mg Q6 will sufce. Since most CSF leaks close
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spontaneously within 48 h (or will be taken care of during
surgery) we do not maintain this regimen beyond hospital day
3, unless there is a signicant amount of bony debris translocated into the parenchyma. If that is the case, 7–10days of
antibiotic coverage can be considered reasonable.
63.9 Prophylactic Hypothermia
Even though preliminary data had shown a possible increase
of survival when induced hypothermia is maintained for
more than 48h in TBI patients, we currently do not use prolonged hypothermia on patients with GSW. Pooled data
(level III) indicated no improvement in overall mortality and
are hinting at increased coagulopathies. Furthermore, RCTs
on hypothermia for severe traumatic brain injury in pediatrics found neither improvement in global functional outcome
nor reduced morality rates. In fact, mortality rates may
increase in hypothermia-treated patients.
63.10 Antiseizure Prophylaxis
Early post-traumatic seizures (PTS) are a common symptom
in acute traumatic brain injury (TBI), their pathophysiology
is extensively studies. Administration of antiseizure-drugs
(ASD) signicantly reduces their occurrence. Therefore,
ASD use is established in the setting of acute head trauma
and PTS and especially in a scenario with a high risk of seizures such as penetrating trauma, severe tissue affection and
hemorrhage. Guidelines recommend ASD use in the rst
7days of injury. If signicant parenchymal damage incurred,
it is reasonable to keep AEDs during the initial period until
the rst follow-up appointment and to then decide about
tapering when long-term use is not indicated.
Phenytoin (PHT) for long has been drug of choice in PTS,
but modern ASD seem as effective as well, e.g., Levetiracetam,
which has advantages in terms of its side effect prole.
Levetiracetam at a target dose of 500–1000mg p.o. or I/V
BID is, therefore, a reasonable alternative.
Penetrating trauma to the head is associated to a high risk
of late post-traumatic seizures, i.e., the development of posttraumatic epilepsy (PTE). However, treating early PTS has
no effect on the occurrence of PTE.Long-term drug treatment is only indicated when late seizures occur after TBI.
63.11 Postoperative Consideration
Excessive postoperative strategies are not topic of this book.
All basic postoperative prophylactic strategies apply for
GSW trauma victims too. A brief reminder follows and your
care protocols should include the following:
• Most patients have a rough clinical course during the rst
3–7days, since swelling seems to peak around POD 3–4
and you have to watch out for it and treat any trends of
increase in ICP early and aggressively.
• Wean all patients from the ventilator ASAP; an extubated patient gives you the best scenario for a proper
assessment and neurological examination, which can be
followed once the GCS is again >8. If the patient does
not regain consciousness soon, opt for an early tracheostomy and PEG in anticipation of a long postoperative
course.
• Ensure full caloric intake by day 7 post-injury to support
wound healing. To achieve best results, begin feeding not
later than 72h after injury.
• Combine mechanical DVT prophylaxis via compression
stockings or intermittent pneumatic compression stockings with low molecular weight heparin or low-dose
unfractionated heparin as early as POD 2.
• Provide a decent bowel regimen (including acid blocker
and a stool softener to help the slowed guts) and for prevention of stress-induced ICU gastritis.
• Supply adequate pain medications as these patients will
not ask for any!
• Support the patient with anxiolytics and sedation in the
setting of ICU care.
• Meticulous decubitus prophylaxis must be applied.
• Mobilize the patient early (PT/OT/out of bed to chair).
63.12 Special Circumstances
If you ever face a situation in which you have multiple GSW
victims (such as a terror attack or a mass casualty), you may
have to make a stern decision: Who is going to be treated
rst, or who is not going to be treated at all. It seems to be
acceptable to make that decision based on your available
resources and based on the available data reecting the different prognosis for patients; We recommend to perform the
work-up in each patient just as outlined above. Based on the
clinical information (presenting GCS score) and the CT
scan, we feel strongly that a patient with a higher GCS and
limited damage on scan (e.g., unilobar right-sided injury) has
the best chances for good functional outcome and hence
should go to surgery rst. However, we acknowledge the
ethical dilemma in this scenario and accept differing decisions based on momentary rationale or experience of the
treating team.
Important Points
• DO NOT PANIC! In many ways, it is a case like many
others; therefore: RUN YOUR ROUTINE. Do all the
work-up and make related decision similar to a decision
tree and according to protocol.
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• DO NOT WASTE TIME—and save it wherever you can
do it safely. This means: When the hospital is notied
about the arrival of a GSW patient, GET READY
BEFORE THEY ARRIVE. Call the OR upfront to get a
trauma room set up for a craniotomy. Announce the most
likely scenario (20-year-old male; R crani/supine or suboccipital crani/prone, etc.). Ask to assemble a team for the
OR that you already know/can work with, do not rely on
newcomers (Fig.63.3).
• GO TO THE ER AND WAIT IN THE TRAUMA BAY
FOR THE PATIENT TO ARRIVE. If you are out of the
hospital, start driving in NOW. Meanwhile organize
things by phone on your way. These are most valuable
minutes that you can save for later (Fig.63.4).
• Touch base with the ER attending. In an experienced
setting, the ER will get prepared ahead of time and have
identication labels/numbers and a trauma team assigned
prior to the patient’s arrival (Fig.63.5).
• Make sure they notify the blood bank for possible need
of products with “emergent release.” Make sure they have
pressors and Mannitol/Lasix IV ready, as well as a respiratory therapist on site to immediately initiate controlled
hyperventilation. Remember the rule of 30 s: height of
bed 30o, hyperventilation with f=30 for a goal pCO2<30.
• Get the trauma team ready in the bay and assign tasks
by talking to the senior/attending running the case. A
GSW IS NOT THE PATIENT TO PRACTICE ON.
Newcomers can stand by and watch, but should stay at a
distance and out of the way! Try to pass all preliminary
information around as it can be gathered from the EMTcall- in from the scene or en route (ask about patient age,
single wound or systemic injury, patient awake or with
loss of consciousness (LOC)/comatose; patient intubated,
patient stable; blood loss at the scene; other issues).
• Call the ER CT scanner upfront that you will bring a
critically ill patient ASAP so they can keep the scanner
FREE for your case!
• Listen well to what the transport team has to say upon
presenting the case, they sometimes know important
details (downtime, seizures at the scene, difculties with
the airway, etc.). Have a second person conrm this information after handover has been done and the EMT team
has a relaxed moment to communicate.
• WATCH if there is any sign of life upon arrival. Get a
good glimpse at the patient (I recommend you stand
behind the chief running the case at the head end of the
patient) and once the primary survey is done.
• You should get a 10–30s neuroexam yourself.
THEN MAKE THE RUN AGAINST THE CLOCK!
Acknowledgment The current chapter is a revision of the original
chapter written by Ekkehard M.Kasper, Yosef Laviv, Martina Stippler,
and Burkhard S.Kasper in the previous edition of the book.
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Approach toPenetrating Injury
https://t.me/medicina_free
oftheSpinal Cord
JoachimM.K.Oertel andJasonR.Degiannis
64.1 Introduction
Trauma to the spine or the spinal cord has an estimated incidence of 7.5%–23.2% of all trauma patients in various large
trauma centers or nationwide registries. Spinal cord injuries
mainly affect the cervical followed by thoracic spine. Very
few spinal cord/conus injuries are related to lumbar spine
injuries.
Penetrating spinal cord injuries (PSCIs) are less common
than spinal cord injuries due to blunt trauma. They can be
classied as either gunshot-wound (GSW)-related or lacerating non-gunshot-wound (non-GSW)-related injuries
(Fig.64.1). These injuries occur most frequently in the thoracic spine.
GSW-related spinal cord injuries have historically mainly
been reported in areas of armed conict. Over the last few
decades, an increase has been seen urban centers, related to
common crime and adverse socio-economic conditions. The
penetrating missile can be a bullet, shrapnel or other foreign
objects, which penetrate the patient’s body via a blast.
In high-velocity (high-energy) gunshot wounds, with a
trajectory in close proximity to the spinal cord, blunt injury
to the dura and/or the spinal cord can occur due to the highenergy shockwave.
In non-GSW injuries the most common weapon is a knife,
but other objects have also been used, such as scissors, screw
drivers, bicycle spokes, etc. It is not uncommon for the
patient to present in the emergency department with a part of
the stabbing object retained under the skin or even protruding through it.
64
Fig. 64.1 Lacerating non-gunshot-wound-related injury. Illustration
by Laura Glücklich
64.2 Evaluation intheEmergency
Department (Fig.64.2)
When confronted with a patient who has sustained a penetrating injury the emergency physician should always adhere
to the ATLS-resuscitation principles. “Impressive” injuries
to where the assault weapon is protruding should not divert
attention from prioritizing the management of the lifethreatening conditions.
J. M. K. Oertel (*) · J. R. Degiannis
Department of Neurosurgery, University Hospital of Saarland,
Homburg-Saar, Germany
e-mail: Joachim.Oertel@uks.eu; Jason.Degiannis@uks.eu
© 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_64
523
524
https://t.me/medicina_free
Fig. 64.2 Standardized
diagnostic work-up.
Illustration by Laura
Glücklich
J. M. K. Oertel and J. R. Degiannis
64.2.1 Neurological Examination
The rst step of the examination aims to determining the
level of the most caudal segment of the spine that has retained
normal sensory and motor function on both sides of the body.
The next step includes the evaluation of the severity of the
neurological decit as complete or incomplete paraplegia
and complete or incomplete quadriplegia. When it comes to
signs of incomplete injury remember that sacral reexes—
the bulbocavernosus reex and the anal wink do not qualify
as sacral sparing. It should be taken into consideration that
the sensory and motor examination is confounded by a
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