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Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma
Injury, Int. J. Care Injured (2004) 35, 320—324
CASE REPORT
Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma Om P. Sharma*, Michael F. Oswanski, Patrick W. White Department of Trauma Services, The Toledo Hospital and Toledo Children’s Hospital, 2142 N. Cove Blvd., Toledo, OH 43606, USA Accepted 5 March 2003
KEYWORDS Blast; Extra-peritoneal; Penetrating; Gunshot; Extra-diaphragmatic; Tangential; CT Scan; Primary blast injury; Secondary blast injury;
Summary Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon. ß 2003 Elsevier Science Ltd. All rights reserved.
Tertiary blast injury
Blunt intestinal trauma (BIT) is relatively uncommon compared to penetrating trauma and can be a diagnostic challenge with a potentially life-threatening outcome. It occurs in less than 1% of blunt abdominal trauma victims.1,13,24 Delayed or missed diagnosis of BIT is frequently associated with high morbidity and mortality.1,7 BIT most commonly results from motor vehicle collisions however, can also be attributed to other blunt forces. Even more rare is the association of blunt force trauma secondary to the blast effects of penetrating gunshot wounds. Currently, violent trends in society worldwide have led to an increased interest in reports of blunt intestinal injuries resulting from blast trauma. Trauma surgeons and emergency room physicians should be aware of the pathophysiology of blast trauma since the initial clinical examination may have subtle findings and be mis*Corresponding author. Tel.: þ1-419-479-2602; fax: þ1-419-479-2604. E-mail address: [email protected] (O.P. Sharma).
leading. In many cases, external evidence of torso trauma may be lacking altogether. Two rare cases of penetrating extra-peritoneal gunshot (and shotgun) wounds (PEGSW) resulting in intestinal trauma are presented.
Case I A 28-year-old male with a history of depression was admitted with a self-inflicted shotgun wound (SGW) of the abdomen located above and to the right of the umbilicus (Fig. 1). The entrance wound was 2 cm 3 cm with powder burns. The exit wound was 8 cm 10 cm in the right flank. The patient was normotensive with mild tachycardia. The abdomen was rigid. A chest radiograph revealed shotgun pellets in the right upper abdomen. The patient’s haemoglobin was 15.5 g/dl, haematocrit 45.5%, white blood cell count 12:8 109 /l and serum amylase 30 units/l. Upon immediate laparotomy, the peritoneum was found to be intact with no retroperitoneal haematoma. There were approximately
0020–1383/$ — see front matter ß 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00102-5
Blast trauma
321
Fig. 1 Smaller medial entrance and larger lateral exit wound in right flank in case I with shotgun trauma.
400 ml of free intraperitoneal blood with contused caecum and a 5 mm perforation on the anterolateral aspect of the caecal wall. A right hemicolectomy with ileocolic anastomosis was done. After closure of the abdomen, all shotgun pellets were irrigated out of the exit wound depths. The patient was discharged on the seventh post-operative day. Daily wet-to-dry dressings were continued and subsequent skin grafting of the wound was successfully performed 5 weeks post-injury.
Case II A 27-year-old male was accidentally shot with a SKS assault rifle (7.62 mm bullet) sustaining a GSW to the left chest. The patient had a blood pressure of 125/85 mmHg, heart rate 105 beats/min, respiratory rate 22 breaths/min and oxygen saturation of 100% on room air. The patient had a 2 cm entrance wound in the left anterior chest wall at the sixth interspace near the mammary line. The exit wound
Fig. 2 Case II with gunshot wound left chest. Arrowhead shows a small medial entrance wound. The larger exit wound is in the left anterolateral chest wall.
322
Om P. Sharma et al.
Fig. 3 Arrowheads pointing to free intraperitoneal air on CT scan in case II with gunshot wound to left chest. This was the only abnormality detected on CT scan.
was 4 cm in the postero-lateral wall about 10 cm away (Fig. 2). The patient was nauseated with no abdominal pain or vomiting. His abdomen was soft with no tenderness. Intestinal sounds were normal. Distal pulsations were intact. Initial laboratory data revealed BUN 9, Na 145, K 3.1, Cl 111, haematocrit 37 (normal 39—49), and serum amylase of 118 units (normal 25—125). The chest radiograph was normal. The patient began to complain of abdominal pain approximately 25 min following his arrival in the emergency centre. He developed mild left upper abdominal tenderness with no rigidity or rebound tenderness. A double-contrast CT scan of the abdomen revealed free intraperitoneal air (Fig. 3), left chest subcutaneous emphysema and no other organ trauma. There was no pneumothorax seen on the chest radiograph or on the CT scan. A laparotomy revealed two 4—5 mm perforations in the colon at the splenic flexure. There was minimal peritoneal contamination with about 100 ml of bloody fluid. There was no injury to the peritoneum, diaphragm, or other intra-abdominal viscera. The retroperitoneum and the lesser sac were normal. Both colonic perforations were repaired in two layers and the abdomen primarily closed with a 10 mm JacksonPratt drain. The patient received cephazolin in the
emergency department but was switched to ceftizoxime and metronidazole intraoperatively. Postoperative chest radiographs remained normal. On exploration of the primary wound, the entrance and exit wounds were found to communicate through the subcutaneous tissue. The GSW was tangential and never entered the chest or abdominal cavities. The wounds were irrigated and gently packed. The postoperative radiographs remained normal. The patient’s post-operative recovery was uneventful. He was started on clear liquids on the second postoperative day and the drain was removed on the third day. The patient was discharged on the sixth post-operative day.
Discussion Injury to intraperitoneal organs can result from blast injuries and have been reported more frequently in the recent literature.3,4,8—10,14,16,18 Blast injuries after an explosion are caused by a sudden increase of the air pressure (primary blast injuries), missiles energised by the blast (secondary injuries), displacement of the victim by the blast wind (tertiary injuries) and by flash burns.16 Primary
Blast trauma
323
blast effects occur in both air and underwater explosions, whereas secondary and tertiary effects occur only in air blasts.3 Lesions are typically located in air-containing organs such as the lungs and the ears. Intra-abdominal injury (bowel rupture) is comparatively more common in immersion blasts.3,9,10 The blast wave is transmitted directly through the abdominal and chest wall causing intestinal and pulmonary damage. In contrast to bombs and other explosive devices, blast injures are infrequently caused by firearms with damage being confined to various depths of the abdominal wall with intact peritoneum. PEGSW of the abdominal wall may cause serious intra-abdominal organ injury.19 In the case of a high velocity gunshot wound, the travelling bullet creates a continuous impact to the tissues throughout its course, with a release of energy to the surrounding tissues.6 The injury potential is related to muzzle velocity and dissipated kinetic energy (KE ¼ 1/2 MV2) and tissue damage along projectile path may be more extensive than suggested by the residual wound tract. Tissue damage in muscle from a high velocity missile can extend 6—7 cm from the wound cavity.6,23 A 0.5—2 cm zone of contusion surrounds the funnel-shaped wound cavity. Beyond this is a concussion zone, well demarcated by leukocytic infiltration. As in the two cases presented, tangential gunshot or shotgun injuries of the abdominal or chest wall can result in injured intra-abdominal viscus due to the transmission of kinetic energy which results in contusion and concussion well within the abdominal cavity despite an intact peritoneum19 and diaphragm. Gunshot wounds can be tangential and extraperitoneal with no peritoneal penetration. Sosa et al. published a prospective management protocol
study for diagnostic laparoscopy in haemodynamically stable abdominal GSW patient in 1995.20 Diagnostic laparoscopy was done in 121 consecutive haemodynamically stable patients comprising 12% of patients with abdominal GSWs. There was no peritoneal penetration in 65% (79/121) of these patients with no delayed laparotomy and no mortality. Overall there was no peritoneal penetration in 11.7% (79/672) of patients with abdominal GSWs. Edwards and Gaspard reported the first case of small bowel (jejunum) perforation due to PEGSW in 1974.5 Ben-Menachen published two additional cases of PEGSW of the abdomen with intra-abdominal injuries; one case had perforation of the antemesenteric terminal ileum and, in the second patient, mesentery of terminal ileum was lacerated with brisk bleeding from the mesenteric arterial branch.2 Kennedy et al. published three cases of GSW of the chest with splenic injury without diaphragmatic or peritoneal penetration.12 Maron and Baker presented a case of PEGSW from an AK-47 with isolated splenic trauma.15 There are two recent reports of small bowel perforations resulting from PEGSW.19,22 The world literature presenting these rare intraabdominal organ traumas resulting from the blast effect of PEGSW and extra-diaphragmatic missile trauma is analysed in Table 1. To this author’s knowledge, the present series describes the first two reported cases of colon injuries from the blast effect of extra-peritoneal PEGSW. The clinician must keep in mind that the initial clinical findings may be minimal or misleading. In a recent report, 68% of the blunt trauma patients had neurological impairment or significant distracting injury compromising reliable clinical examination.13 Failure to recognise the potential for hollow viscus injury
Table 1 Intraperitoneal organ injuries in thoraco-abdominal penetrating extra-peritoneal gunshot (shotgun) wounds (PEGSW) Author
Aetiology
Organ trauma
Therapy
GSW abdomen
Jejunal perforation
Repaired
GSW abdomen GSW abdomen
Terminal ileal perforation Terminal ileal mesentery
Repaired Ligation arterial bleeder
Kennedy et al.12
GSW chest GSW chest GSW chest
Spleen: capsular tear Spleen: capsular tear Spleen: 6 cm 1.5 cm tear
Left undisturbed Left undisturbed Splenorraphy
Maron and Baker15 Sasaki and Mittal19 Velitchkov et al.22
GSW chest GSW abdomen GSW abdomen
Spleen: stellate laceration Jejunal perforation Mid-ileum perforation
Splenectomy Repaired Resection and anastomosis
Present report
SGW abdomen GSW chest
Caecum perforation Colonic perforation 2
Right colectomy, ileocolic anastomosis Repaired
Edwards and Gaspard5 Ben-Menachem
2
324
can result in increased morbidity and mortality. The delay in diagnosis and operative repair of small bowel injury accounted for half of the deaths in one report.7 Relative lack of clinical findings should not deter the physician from pursuing other pertinent diagnostic work up with close observation. A high index of suspicion of possible occult intestinal trauma must be based on the mechanism of trauma, possible deviation of the bullet trajectory and a thorough understanding of pathophysiology of blast trauma. Apart from careful clinical observation, pertinent diagnostic tests such as CT scans, sonography,21 diagnostic peritoneal lavage,11,17 laparoscopy20,25 and even laparotomy may be indicated. Timely operative repair of intestinal trauma is of the essence.
Acknowledgements The Authors would like to thank Shekhar S. Raj, MBBS Adult Trauma Coordinator, for his help in doing the revision of the manuscript.
References 1. Allen GS, et al. Delayed diagnosis of blunt duodenal injury: an avoidable complication. J Am Coll Surg 1998;187(4): 393—9. 2. Ben-Menachem Y. Intra-abdominal injuries in nonpenetrating gunshot wounds of the abdominal wall: two unusual cases. J Trauma 1979;19(3):207—11. 3. Brismar B, Bergenwald L. The terrorist bomb explosion in Bologna, Italy, 1980: an analysis of the effects and injuries sustained. J Trauma 1982;22(3):216—20. 4. Cripps NP, Glover MA, Guy RJ. The pathophysiology of primary blast injury and its implications for treatment. Part II. The auditory structures and abdomen. J R Nav Med Serv 1999;85(1):13—24. 5. Edwards J, Gaspard DJ. Visceral injury due to extraperitoneal gunshot wounds. Arch Surg 1974;108(6):865—6. 6. Fackler ML, Bellamy RF, Malinowski JA. The wound profile: illustration of the missile-tissue interaction. J Trauma 1988;28(Suppl 1):S21—9. 7. Fakhry SM, et al. Relatively short diagnostic delays (<8 h) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicentre experience. J Trauma 2000;48(3): 408—14, discussion 414—5.
Om P. Sharma et al.
8. Feliciano DV, et al. Management of casualties from the bombing at the centennial Olympics. Am J Surg 1998;176(6): 538—43. 9. Huller T, Bazini Y. Blast injuries of the chest and abdomen. Arch Surg 1970;100(1):24—30. 10. Irwin RJ, et al. Cardiopulmonary physiology of primary blast injury. J Trauma 1997;43(4):650—5. 11. Kelemen III JJ, et al. Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen. Arch Surg 1997;132(8):909—13. 12. Kennedy FR, Fleming AW, Scott RS. Splenic injury from gunshot wounds to the chest without diaphragmatic or peritoneal violation: case reports. J Trauma 1991;31(11): 1561—2. 13. Malhotra AK, et al. Blunt bowel and mesenteric injuries: the role of screening computed tomography. J Trauma 2000; 48(6):991—8, discussion 998—1000. 14. Mallonee S, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. J Am Med Assoc 1996; 276(5):382—7. 15. Maron S, Baker MS. Splenic rupture due to extraperitoneal gunshot wound: use of peritoneal lavage in the low-tech environment. Mil Med 1994;159(3):249—50. 16. Mellor SG, Cooper GJ. Analysis of 828 servicemen killed or injured by explosion in northern Ireland 1970—1984: the hostile action casualty system. Br J Surg 1989;76(10): 1006—10. 17. Nagy KK, et al. Prognosis of penetrating trauma in elderly patients: a comparison with younger patients. J Trauma 2000;49(2):190—3, discussion 193—4. 18. Paran H, et al. Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation? J Trauma 1996;40(3):472—5. 19. Sasaki LS, Mittal VK. Small bowel laceration from a penetrating extraperitoneal gunshot wound: a case report [published erratum appears in J Trauma 1995;39(6):1218]. J Trauma 1995;39(3):602—4. 20. Sosa JL, et al. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma 1995;39(3):501—4, discussion 504—6. 21. Udobi KF, et al. Role of Ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 2001;50(3):475—9. 22. Velitchkov NG, et al. Delayed small bowel injury as a result of penetrating extraperitoneal high-velocity ballistic trauma to the abdomen. J Trauma 2000;48(1):169—70. 23. Wang ZG, et al. Early pathomorphologic characteristics of the wound track caused by fragments. J Trauma 1988; 28(Suppl):S89—95. 24. Wisner DH, Chun Y, Blaisdell FW. Blunt intestinal injury. Keys to diagnosis and management. Arch Surg 1990;125(10): 1319—22, discussion 1322—3. 25. Zantut LF, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicentre experience. J Trauma 1997;42(5):825—9, discussion 829—31.
CASE REPORT
Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma Om P. Sharma*, Michael F. Oswanski, Patrick W. White Department of Trauma Services, The Toledo Hospital and Toledo Children’s Hospital, 2142 N. Cove Blvd., Toledo, OH 43606, USA Accepted 5 March 2003
KEYWORDS Blast; Extra-peritoneal; Penetrating; Gunshot; Extra-diaphragmatic; Tangential; CT Scan; Primary blast injury; Secondary blast injury;
Summary Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon. ß 2003 Elsevier Science Ltd. All rights reserved.
Tertiary blast injury
Blunt intestinal trauma (BIT) is relatively uncommon compared to penetrating trauma and can be a diagnostic challenge with a potentially life-threatening outcome. It occurs in less than 1% of blunt abdominal trauma victims.1,13,24 Delayed or missed diagnosis of BIT is frequently associated with high morbidity and mortality.1,7 BIT most commonly results from motor vehicle collisions however, can also be attributed to other blunt forces. Even more rare is the association of blunt force trauma secondary to the blast effects of penetrating gunshot wounds. Currently, violent trends in society worldwide have led to an increased interest in reports of blunt intestinal injuries resulting from blast trauma. Trauma surgeons and emergency room physicians should be aware of the pathophysiology of blast trauma since the initial clinical examination may have subtle findings and be mis*Corresponding author. Tel.: þ1-419-479-2602; fax: þ1-419-479-2604. E-mail address: [email protected] (O.P. Sharma).
leading. In many cases, external evidence of torso trauma may be lacking altogether. Two rare cases of penetrating extra-peritoneal gunshot (and shotgun) wounds (PEGSW) resulting in intestinal trauma are presented.
Case I A 28-year-old male with a history of depression was admitted with a self-inflicted shotgun wound (SGW) of the abdomen located above and to the right of the umbilicus (Fig. 1). The entrance wound was 2 cm 3 cm with powder burns. The exit wound was 8 cm 10 cm in the right flank. The patient was normotensive with mild tachycardia. The abdomen was rigid. A chest radiograph revealed shotgun pellets in the right upper abdomen. The patient’s haemoglobin was 15.5 g/dl, haematocrit 45.5%, white blood cell count 12:8 109 /l and serum amylase 30 units/l. Upon immediate laparotomy, the peritoneum was found to be intact with no retroperitoneal haematoma. There were approximately
0020–1383/$ — see front matter ß 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(03)00102-5
Blast trauma
321
Fig. 1 Smaller medial entrance and larger lateral exit wound in right flank in case I with shotgun trauma.
400 ml of free intraperitoneal blood with contused caecum and a 5 mm perforation on the anterolateral aspect of the caecal wall. A right hemicolectomy with ileocolic anastomosis was done. After closure of the abdomen, all shotgun pellets were irrigated out of the exit wound depths. The patient was discharged on the seventh post-operative day. Daily wet-to-dry dressings were continued and subsequent skin grafting of the wound was successfully performed 5 weeks post-injury.
Case II A 27-year-old male was accidentally shot with a SKS assault rifle (7.62 mm bullet) sustaining a GSW to the left chest. The patient had a blood pressure of 125/85 mmHg, heart rate 105 beats/min, respiratory rate 22 breaths/min and oxygen saturation of 100% on room air. The patient had a 2 cm entrance wound in the left anterior chest wall at the sixth interspace near the mammary line. The exit wound
Fig. 2 Case II with gunshot wound left chest. Arrowhead shows a small medial entrance wound. The larger exit wound is in the left anterolateral chest wall.
322
Om P. Sharma et al.
Fig. 3 Arrowheads pointing to free intraperitoneal air on CT scan in case II with gunshot wound to left chest. This was the only abnormality detected on CT scan.
was 4 cm in the postero-lateral wall about 10 cm away (Fig. 2). The patient was nauseated with no abdominal pain or vomiting. His abdomen was soft with no tenderness. Intestinal sounds were normal. Distal pulsations were intact. Initial laboratory data revealed BUN 9, Na 145, K 3.1, Cl 111, haematocrit 37 (normal 39—49), and serum amylase of 118 units (normal 25—125). The chest radiograph was normal. The patient began to complain of abdominal pain approximately 25 min following his arrival in the emergency centre. He developed mild left upper abdominal tenderness with no rigidity or rebound tenderness. A double-contrast CT scan of the abdomen revealed free intraperitoneal air (Fig. 3), left chest subcutaneous emphysema and no other organ trauma. There was no pneumothorax seen on the chest radiograph or on the CT scan. A laparotomy revealed two 4—5 mm perforations in the colon at the splenic flexure. There was minimal peritoneal contamination with about 100 ml of bloody fluid. There was no injury to the peritoneum, diaphragm, or other intra-abdominal viscera. The retroperitoneum and the lesser sac were normal. Both colonic perforations were repaired in two layers and the abdomen primarily closed with a 10 mm JacksonPratt drain. The patient received cephazolin in the
emergency department but was switched to ceftizoxime and metronidazole intraoperatively. Postoperative chest radiographs remained normal. On exploration of the primary wound, the entrance and exit wounds were found to communicate through the subcutaneous tissue. The GSW was tangential and never entered the chest or abdominal cavities. The wounds were irrigated and gently packed. The postoperative radiographs remained normal. The patient’s post-operative recovery was uneventful. He was started on clear liquids on the second postoperative day and the drain was removed on the third day. The patient was discharged on the sixth post-operative day.
Discussion Injury to intraperitoneal organs can result from blast injuries and have been reported more frequently in the recent literature.3,4,8—10,14,16,18 Blast injuries after an explosion are caused by a sudden increase of the air pressure (primary blast injuries), missiles energised by the blast (secondary injuries), displacement of the victim by the blast wind (tertiary injuries) and by flash burns.16 Primary
Blast trauma
323
blast effects occur in both air and underwater explosions, whereas secondary and tertiary effects occur only in air blasts.3 Lesions are typically located in air-containing organs such as the lungs and the ears. Intra-abdominal injury (bowel rupture) is comparatively more common in immersion blasts.3,9,10 The blast wave is transmitted directly through the abdominal and chest wall causing intestinal and pulmonary damage. In contrast to bombs and other explosive devices, blast injures are infrequently caused by firearms with damage being confined to various depths of the abdominal wall with intact peritoneum. PEGSW of the abdominal wall may cause serious intra-abdominal organ injury.19 In the case of a high velocity gunshot wound, the travelling bullet creates a continuous impact to the tissues throughout its course, with a release of energy to the surrounding tissues.6 The injury potential is related to muzzle velocity and dissipated kinetic energy (KE ¼ 1/2 MV2) and tissue damage along projectile path may be more extensive than suggested by the residual wound tract. Tissue damage in muscle from a high velocity missile can extend 6—7 cm from the wound cavity.6,23 A 0.5—2 cm zone of contusion surrounds the funnel-shaped wound cavity. Beyond this is a concussion zone, well demarcated by leukocytic infiltration. As in the two cases presented, tangential gunshot or shotgun injuries of the abdominal or chest wall can result in injured intra-abdominal viscus due to the transmission of kinetic energy which results in contusion and concussion well within the abdominal cavity despite an intact peritoneum19 and diaphragm. Gunshot wounds can be tangential and extraperitoneal with no peritoneal penetration. Sosa et al. published a prospective management protocol
study for diagnostic laparoscopy in haemodynamically stable abdominal GSW patient in 1995.20 Diagnostic laparoscopy was done in 121 consecutive haemodynamically stable patients comprising 12% of patients with abdominal GSWs. There was no peritoneal penetration in 65% (79/121) of these patients with no delayed laparotomy and no mortality. Overall there was no peritoneal penetration in 11.7% (79/672) of patients with abdominal GSWs. Edwards and Gaspard reported the first case of small bowel (jejunum) perforation due to PEGSW in 1974.5 Ben-Menachen published two additional cases of PEGSW of the abdomen with intra-abdominal injuries; one case had perforation of the antemesenteric terminal ileum and, in the second patient, mesentery of terminal ileum was lacerated with brisk bleeding from the mesenteric arterial branch.2 Kennedy et al. published three cases of GSW of the chest with splenic injury without diaphragmatic or peritoneal penetration.12 Maron and Baker presented a case of PEGSW from an AK-47 with isolated splenic trauma.15 There are two recent reports of small bowel perforations resulting from PEGSW.19,22 The world literature presenting these rare intraabdominal organ traumas resulting from the blast effect of PEGSW and extra-diaphragmatic missile trauma is analysed in Table 1. To this author’s knowledge, the present series describes the first two reported cases of colon injuries from the blast effect of extra-peritoneal PEGSW. The clinician must keep in mind that the initial clinical findings may be minimal or misleading. In a recent report, 68% of the blunt trauma patients had neurological impairment or significant distracting injury compromising reliable clinical examination.13 Failure to recognise the potential for hollow viscus injury
Table 1 Intraperitoneal organ injuries in thoraco-abdominal penetrating extra-peritoneal gunshot (shotgun) wounds (PEGSW) Author
Aetiology
Organ trauma
Therapy
GSW abdomen
Jejunal perforation
Repaired
GSW abdomen GSW abdomen
Terminal ileal perforation Terminal ileal mesentery
Repaired Ligation arterial bleeder
Kennedy et al.12
GSW chest GSW chest GSW chest
Spleen: capsular tear Spleen: capsular tear Spleen: 6 cm 1.5 cm tear
Left undisturbed Left undisturbed Splenorraphy
Maron and Baker15 Sasaki and Mittal19 Velitchkov et al.22
GSW chest GSW abdomen GSW abdomen
Spleen: stellate laceration Jejunal perforation Mid-ileum perforation
Splenectomy Repaired Resection and anastomosis
Present report
SGW abdomen GSW chest
Caecum perforation Colonic perforation 2
Right colectomy, ileocolic anastomosis Repaired
Edwards and Gaspard5 Ben-Menachem
2
324
can result in increased morbidity and mortality. The delay in diagnosis and operative repair of small bowel injury accounted for half of the deaths in one report.7 Relative lack of clinical findings should not deter the physician from pursuing other pertinent diagnostic work up with close observation. A high index of suspicion of possible occult intestinal trauma must be based on the mechanism of trauma, possible deviation of the bullet trajectory and a thorough understanding of pathophysiology of blast trauma. Apart from careful clinical observation, pertinent diagnostic tests such as CT scans, sonography,21 diagnostic peritoneal lavage,11,17 laparoscopy20,25 and even laparotomy may be indicated. Timely operative repair of intestinal trauma is of the essence.
Acknowledgements The Authors would like to thank Shekhar S. Raj, MBBS Adult Trauma Coordinator, for his help in doing the revision of the manuscript.
References 1. Allen GS, et al. Delayed diagnosis of blunt duodenal injury: an avoidable complication. J Am Coll Surg 1998;187(4): 393—9. 2. Ben-Menachem Y. Intra-abdominal injuries in nonpenetrating gunshot wounds of the abdominal wall: two unusual cases. J Trauma 1979;19(3):207—11. 3. Brismar B, Bergenwald L. The terrorist bomb explosion in Bologna, Italy, 1980: an analysis of the effects and injuries sustained. J Trauma 1982;22(3):216—20. 4. Cripps NP, Glover MA, Guy RJ. The pathophysiology of primary blast injury and its implications for treatment. Part II. The auditory structures and abdomen. J R Nav Med Serv 1999;85(1):13—24. 5. Edwards J, Gaspard DJ. Visceral injury due to extraperitoneal gunshot wounds. Arch Surg 1974;108(6):865—6. 6. Fackler ML, Bellamy RF, Malinowski JA. The wound profile: illustration of the missile-tissue interaction. J Trauma 1988;28(Suppl 1):S21—9. 7. Fakhry SM, et al. Relatively short diagnostic delays (<8 h) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicentre experience. J Trauma 2000;48(3): 408—14, discussion 414—5.
Om P. Sharma et al.
8. Feliciano DV, et al. Management of casualties from the bombing at the centennial Olympics. Am J Surg 1998;176(6): 538—43. 9. Huller T, Bazini Y. Blast injuries of the chest and abdomen. Arch Surg 1970;100(1):24—30. 10. Irwin RJ, et al. Cardiopulmonary physiology of primary blast injury. J Trauma 1997;43(4):650—5. 11. Kelemen III JJ, et al. Evaluation of diagnostic peritoneal lavage in stable patients with gunshot wounds to the abdomen. Arch Surg 1997;132(8):909—13. 12. Kennedy FR, Fleming AW, Scott RS. Splenic injury from gunshot wounds to the chest without diaphragmatic or peritoneal violation: case reports. J Trauma 1991;31(11): 1561—2. 13. Malhotra AK, et al. Blunt bowel and mesenteric injuries: the role of screening computed tomography. J Trauma 2000; 48(6):991—8, discussion 998—1000. 14. Mallonee S, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. J Am Med Assoc 1996; 276(5):382—7. 15. Maron S, Baker MS. Splenic rupture due to extraperitoneal gunshot wound: use of peritoneal lavage in the low-tech environment. Mil Med 1994;159(3):249—50. 16. Mellor SG, Cooper GJ. Analysis of 828 servicemen killed or injured by explosion in northern Ireland 1970—1984: the hostile action casualty system. Br J Surg 1989;76(10): 1006—10. 17. Nagy KK, et al. Prognosis of penetrating trauma in elderly patients: a comparison with younger patients. J Trauma 2000;49(2):190—3, discussion 193—4. 18. Paran H, et al. Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation? J Trauma 1996;40(3):472—5. 19. Sasaki LS, Mittal VK. Small bowel laceration from a penetrating extraperitoneal gunshot wound: a case report [published erratum appears in J Trauma 1995;39(6):1218]. J Trauma 1995;39(3):602—4. 20. Sosa JL, et al. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma 1995;39(3):501—4, discussion 504—6. 21. Udobi KF, et al. Role of Ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 2001;50(3):475—9. 22. Velitchkov NG, et al. Delayed small bowel injury as a result of penetrating extraperitoneal high-velocity ballistic trauma to the abdomen. J Trauma 2000;48(1):169—70. 23. Wang ZG, et al. Early pathomorphologic characteristics of the wound track caused by fragments. J Trauma 1988; 28(Suppl):S89—95. 24. Wisner DH, Chun Y, Blaisdell FW. Blunt intestinal injury. Keys to diagnosis and management. Arch Surg 1990;125(10): 1319—22, discussion 1322—3. 25. Zantut LF, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicentre experience. J Trauma 1997;42(5):825—9, discussion 829—31.