Ballistic Trauma

Epidemiology and Risk Factors

Pathophysiology

  • Temporary cavitation
    • Devitalise surrounding tissue 30-40× diameter of projectile
    • Vacuum draws in surrounding debris, contaminating the devitalised tract

Bullets are not sterilised by firing.

Aetiology

Clinical Manifestations

Diagnostic Approach and DDx

Investigations

Bedside:

Laboratory:

Imaging:

Other:

Management

  • Early wound excision and irrigation
  • Delayed primary closure
  • Antibiotics and ADT
  • Early physical therapy

Resuscitation:

Specific therapy:

  • Pharmacological
    • Adjuvant antibiotics
    • Tetanus booster
  • Procedural
    • Early and thorough wound excision and irrigation
    • Delayed primary closure
      • Exceptions are wounds:
        • To head, neck and genitals
          Adequate blood supply to permit healing despite contamination.
        • Not penetrating deep fascia
      • Wound inspection every 24-48 hours until debridement completed and wound closed
      • 20% of patients will need ⩾4 procedures
    • Projectiles should only be removed if they are:
      • Easily accessible
      • In joints
        May cause lead arthropathy.
      • In subarachnoid space
        Lead-related neurotoxicity. Notably, projectiles in the brain should not be removed.
      • Source of infection
      • Risking erosion
        Cardiac, bronchus.
      • Causing persistent pain
  • Physical
    • Early physical therapy

Supportive care:

Disposition:

Preventative:

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

Prognosis

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.