Welcome everybody to today's webinar. Today's webinar, the title is Management of High Velocity Gunshot Wounds in the Pediatric Population. Our speaker today is Dr. Trey Eubanks. He is a teaching faculty member of the University of Tennessee Health Science Center. He's a trauma medical director for Le Bonheur Children's Hospital and chief of the Division of Pediatric Surgery at the University of Tennessee Health Science Center, where he holds the position as an associate professor of surgery and pediatrics. Dr. Eubanks serves on the TCAA board and on the Pediatric Committee and join me in welcoming Dr. Eubanks today for this fascinating talk. Well good afternoon. We're going to go through kind of the physics of gunshot wounds and then talk about three patient scenarios and we'll have some, we'll be watching the chat for questions and hopefully have some time for questions at the end. So let's get started. Let's see, I have no commercial interest to disclose. We're going to talk about resuscitation goals and pediatric penetrating trauma, about operative decision making and multi-departmental injuries, and specifically about a case of a common bile duct injury and how to manage that. So bullets can be small or large, slow or fast. Any of you who've watched Dirty Harry know a little bit about what's described as the most powerful handgun in the world, which is the 44 magnum. And when you hear about the 44s and 38s, I'll talk about what that means. Knife stab wounds and arrows are considered extremely low energy, obviously, but when we talk about low energy, I'm talking about low energy handguns. And so a handgun normally fires somewhere between 700 and 1200 foot per second. That's muzzle velocity. That's how fast the projectile is moving. That's also true for shotguns and some low-powered rifles, but most rifles have a muzzle velocity of between 1800 and 3000 foot per second. The bullet length can increase the bullet tumbling, which impacts tissue injury. It does reduce accuracy of the shot, but if a tumbling bullet tends to do more damage when it strikes the target, and the way to make it more accurate and tumble less is by rifling the rifle, which is where they kind of put a groove in it so that the barrel spins. And that's what you hear about on some of the investigative shows of how they identify a bullet matching it with an injury. Yaw is just the gyroscopic effect of the center of axis of the bullet as it tumbles. And again, a tumbling bullet is going to release a lot more kinetic injury and cause more tissue damage when it strikes. Some key terms to know about cavitation, when you are hit with a bullet, there's a temporary and then a permanent cavity that's formed, and I'll show you an example of that. I've already described high and low velocity, the difference, and the cutoff is about 1800 foot per second on high and low velocity firearms. A hollow point, which you may hear about a bullet, you just think about a mushroom bullet, some people call it, but it mushrooms out when it strikes the target, as opposed to a very pointed bullet, which will tend to go through a target and not spread out as much. So they cause much more damage, they release more energy upon impact. Any shells that are considered a magnum shell will have much more energy delivered. The caliber is what you're talking about when you're talking about a .44 magnum. A .44, a .38, a .40, that refers to, it's actually .44. So that's how many inches in diameter the projectile is. You'll also hear about bullets caliber described in millimeters. So you have seven millimeter, a nine millimeter, and a lot of people think a nine millimeter is actually the largest projectile that can be fired from a handgun, but actually the .44 and the .40 are both larger because a nine millimeter is only .38 inches wide. And then the jacket, full metal jacket was a movie, that's the metal covering over the bullet on the outside. So here's an example of what the cavitation looks like. If you see in this image, this was a bullet that was fired. The entry is on the far right, the exit's on the left, fired through this kind of a cast, that made this cast of what the cavity, and this is the initial cavitation that's caused. It's temporary, but this is kind of a shockwaves in the cavitation that you see caused by a projectile. I believe this was a .38. The effect of the bullet is based on the tissue that it strikes in some ways, like less elastic tissue like muscle and liver, bone obviously will get damaged more, there'll be a lot more obvious tissue damage there, whereas a more elastic tissue like bowel and lung tends to have smaller areas of damage. And the process of a bullet as it strikes the as it strikes the object, the tip will impact the tissue, pushes forward through the tissues, and then pushes a tissue wave off to the side. And a shockwave is produced that pushes forward and laterally and moves along the bullet path, and then the waves move perpendicular to the bullet path. It causes rapid compression, coarse tearing and crushing of the tissue, and then behind the bullet there's a cavity that's formed that actually will suck debris into the bullet pathway. Entrance wounds are usually about the size of the bullet, especially those that are not the hollow point bullets, the non-deforming type. Deforming bullets like a mushroom type bullet can cause a larger injury. And then at close range you'll have powder burns, you may have a one to two millimeter circle of discoloration around the impact site, and you may have subcutaneous emphysema at the site where air was kind of sucked into the wound. Exit wounds usually appear much larger, blown out, you kind of see a pressure wave effect. Now this is the physics part of the talk. So energy transfer is based on a formula. The energy is half the mass times velocity squared, where mass is the mass in grains, velocity is in foot per second. The mass, excuse me, the energy dispersed is in foot pounds, so there's an easy way to convert that, which is mass times velocity squared divided by 450,435, which converts all this into foot pound energy. So a high velocity projectile like what you'd see in an AR-15, an M4, AK-47, those go at about 3,200 foot per second muzzle velocity. But the bullet grain, the bullet size is actually small by comparison to some handguns, only 55 grains size bullet. But because of the muzzle velocity is 3,200 feet per second, and you square that number, it produces a lot more energy. The energy disburses 1,265 foot pounds, for example, for an AR-15. The low velocity weapons like a 38, a 40, 44, or a nine millimeter handgun usually have about a 1,200 foot per second muzzle velocity. They're much bigger, 115 grains or so, they can get bigger than that, but still they only put out about 500 foot pounds of pressure, still a lot of energy, but nothing, you know, it can be a third of what you get with a high velocity rifle. So there's a little transition slide here, this is Phil Mott, this is the top of the tooth of time, and that's my son after a long hike. So as far as resuscitation goals on children with gunshot wounds, it's very similar to a lot of trauma patients, but you don't have to worry about a whole lot of figuring out what's injured as we do with blood trauma. So most of the resuscitation goals focus around, just like with any fluid resuscitation, restoring the adequate tissue perfusion, which we measure by looking at correcting of lactate acidosis, and then replacing products that are lost, blood, coagulation factors, platelets. And then the third thing, which I think is often not remembered, is maintaining body temperature. In a couple of these cases that we're going to talk about, maintaining body temperature is particularly important, and in kids in general with gunshot wounds, especially young children, it becomes important when it's a abdominal gunshot wound, and we'll talk about that in just a minute. So this is our first case, but this is a low velocity gunshot wound, a patient by the name of MC. He was a five-year-old, is a five-year-old, who was accidentally shot by his older brother at close range, upstairs, away from the parents. He ran downstairs, reportedly holding his guts, according to his dad. EMS arrived, and he was awake and alert. They placed an IV. They gave him about 200 cc's of fluid and gave him some fentanyl. They covered his eviscerated bowel with a wrap to maintain, to keep pressure off of it, even having to hold it, but also to kind of maintain its temperature and to stop any oozing that was going on. And then he was brought to our hospital by our ambulance, which was from about 125 miles away. The firearm used was a Glock 40 caliber with hollow point cartridges, so it was a mushroom type bullet, but a 40 caliber, which is pretty good size, and it was discharged at close range. He arrived 80 minutes after the accident at our emergency department. He was awake and alert. His vital signs are pretty good. Blood pressure is good. Heart rate's a little high. His lab work, as you can see there, his hemoglobin was 9.9, hematocrit was 29. His blood gas was essentially normal, and his lactate was normal. So that's all good stuff. So he's not really in shock yet. He's lost some fluid, obviously, which you knew about looking at him, but at this point, we're not really in any degree of shock. So from a standpoint of resuscitation, the thing you want to think about in this case is he's awake and alert and he's not actively bleeding. So we really don't have to continue to give him a bunch of fluids. This is something really we learned a lot from the Iraq conflict. The way that they would treat soldiers in the field is if they could feel a pulse, and if the soldier was awake and alert, they didn't give them fluids. They just stuck an IV in them. Now, I'm not saying we never give any fluids, and we shouldn't necessarily, we can't exactly take all battlefield accidents and trauma and convert them, but in the urban trauma centers or in trauma centers that take a lot of gunshot wounds, you definitely could use some of that science and experience and apply it to our patients. So this is an x-ray that was taken of the patient, and I just wanted to point out a couple of things on this x-ray. One is you probably can tell, but there's a bowel hanging out here. All this is extra abdominal bowel here, and the other thing is it's a very large stomach bubble, which a five-year-old child is going to cry a lot and swallow a lot of gas, which is going to cause his stomach to distend. So in very short order, we took him up to the operating room, and this is what it looked like before we even started proceeding with prepping his abdomen. So on the far right of this picture, you'll see that's the entry site. There's some bruising there. There's a little kind of a burn there. It was very close, and the exit site is all under here, all this. At this spot here where it's a little discolored is where he had a single colon injury on the mesenteric border. So what we found was a large and small bowel evisceration from the gunshot wound and a 25% circumference transverse colon injury on the anti-mesenteric border. He also had a traumatic mental hernia, obviously, and some soft tissue damage, which is going to be a theme kind of that we'll talk about as we go on, and it's very common in small children with firearm injuries to the abdomen because they just don't have a lot of soft tissue and the energy disperse is so great. Now this is what happens when you have these patients that have significant tissue destruction. So this child is on post-op day five. So we repaired the colon. We sent him to the floor. His wound was sewn together and had some corners on it. Whenever you have a wound that you have to repair that has a corner, that corner is always going to be very susceptible to becoming ischemic and dying. So we watched this wound very closely, and every day it would look a little more red or purple. Never really developed much in the form of cellulitis until really the kind of last day, which was this day before we decided to go back to the operating room. But the thing to look out for on this patient would have been, from a nursing standpoint, would have been watching for fever, watching wound changes, and watching for surrounding erythema. We typically debride these gunshot wounds, particularly at the entrance and exit site, by taking a core of skin and a little bit of soft tissue around it to prevent secondary infection. Because as I said, particularly on the entry site, that will suck in clothes, you know, drywall, whatever they go through into that wound, and they'll get a wound infection. And that was done in these cases. But still, because of the concussion effect, the tissue was just destroyed, and it took a while to kind of declare itself. So look at this almost like you would maybe a burn that you're not sure is deep enough to require skin grafting. But he stayed in the hospital the whole time. We were waiting bowel function to return. But eventually, we knew this was going to have to go back to the operating room for a debridement. So from left to right, you've got the picture. This is the left picture is the very first day when we took him back and debrided all that skin and soft tissue that was ischemic. And then we applied a back sponge after a wash out a couple of days later, and eventually got kind of this image, which is the middle picture, which has a lot more a lot of granulation tissue, a lot more healthy tissue in the center. The fascia is a little bit grungy. So we cleaned that up, and then closed the tissue over the top. As you see in the picture on the far right. This is actually when he came back to clinic and had these sutures removed. And it doesn't look very pretty. But that's really the best you could have gotten out of a wound this big. And this child had to go through multiple operations. Sorry, this is my transition slide. I had to go through multiple operations to get that point, but it's done well really post-optively. This is a little fishing trip I took with some family. That's my son and I in the middle. And then the two gentlemen on the left and the guy on the far right are from California. And we were boarding this boat in Alabama on the Gulf Coast. The captain said, where is everybody from? And everyone said, I'm from Tennessee or Mississippi or Alabama or wherever. And those guys are all from California. So they said, we're from California. He said, welcome to America, which was kind of funny. Okay, the next two cases are high velocity gunshot wounds. And maybe can kind of display some of the differences that we see versus that low velocity gunshot wound. But one of the points I want you to remember that in small kids, even a low velocity gunshot wound is going to cause a lot of tissue damage. But they don't typically traverse multiple cavities, not nearly as frequently. So this was a child who was right here in Memphis, whose family said that the house was shot up in a drive-by shooting. The child was asleep. Bullets go off, guns go off. And this child is found down. Now, Memphis Police Department were on the scene before EMS made it there. But EMS was there very quickly. When they got there, a Memphis police officer was holding the child in his arms. The child was awake and alert. Vitals were good. Blood pressure was 110 over 40. Heart rate 134. They placed an IV, and they started some oxygen, and they brought him to the emergency room. On arrival, the blood pressure was still good, 130 over 88. Heart rate is 154. He's still awake and alert. He's got a very small wound in his back at around L2, and then an exit wound in his right upper quadrant with small bowel evisceration. Again, that's his x-ray, and you can see on the lateral side of that x-ray, loops of bowel kind of hanging outside of the skin there. Labs were listed below, and the x-ray I've got shown here, and he was taken to the operating room very quickly at 2130. Really not a lot of workup that you need to do in the emergency room for something like this. It's obvious they're going to have to go to the operating room. You really want to give them fluids to resuscitate them if that's needed, and you want to warm them up, and then you want to get a type and cross. Here's the lab work that was done on this patient, and the two things I would immediately turn my attention to are the hemoglobin and the lactate. This kid was in some degree of shock because the lactic acid is 4.4. Hemoglobin is 9.5. We're already thinking about this child's going to need a blood transfusion, definitely need some volume resuscitation. How you resuscitate the child is going to be the big key, and that's kind of the nuance of how to get the best results in these patients. If I know a kid's going to need volume, and they're anemic, and I anticipate them becoming more anemic, then it only makes sense instead of just giving them pristaloid, that I'd rather give them blood, FFP, and platelets in as much of a one-to-one fashion as I possibly can. The things to ask about on this kid is surgical approach. I don't think there's anybody here that would do a laparoscopy on this child because he's got an evisceration, but I'm sure someone would consider it. What now? You're going to lap the patient. You're going to do an open operation. Upon entering this kid's abdomen, the evisceration was just to the right of midline, about an inch off the midline. So we went on a midline incision. There was obvious blood in the abdomen, which we immediately evacuated. We saw an obvious injury to the liver right next to the gallbladder, and then we saw a transverse colon injury that was pretty obvious. So we controlled that. We packed the liver. We controlled the stool flow out of the colon, and then we noticed there was a lot of blood in Morris's pouch, and it looked to be some bleeding coming from the colon mesentery, and then there was a large hematoma in zone one. So zone one, as you know, runs right over the aorta and the vena cava, right in the middle of the abdomen, and any zone really that gets zone one, two, and three that gets a penetrating injury needs to be explored if you see a hematoma there. In blunt trauma, it's managed differently. Only zone one injuries need to be explored. Zone two injuries, which are over the kidney and adrenal glands, only explored when expanding, and zone three injuries on blunt trauma you shouldn't explore because that's usually a pelvic fracture. This was a zone run one hematoma, more pronounced on the right side of midline, which is where, of course, the bullet track was, and so we decided to explore that and open it, and to explore the retroperitoneal hematoma in that area requires a medial visceral rotation called a cattail brash maneuver, and that's where you incise, you cocherize the duodenum, incise the white line at the throat, then you take the small bowel and rotate it all the way up until you can expose the entire cava from the renal vessels down to the bifurcation, and you can actually completely expose, you can expose a part of the retropatic cava, so you can go fairly high if you need to, and then you rotate all that up, you identify the bleeding site, and then control the bleeding. A left-sided, a more left-sided focused hematoma, or one where you think it's coming from the aorta, which usually are going to be obvious because it's going to be putting out blood a little bit quicker, you need to do a Maddox maneuver, which is a left medial visceral rotation. So in this child, what we identified was an infarenal, inferior vena cava injury was about four centimeters long, and it was about 50 percent of the circumference of the inferior vena cava. The bleeding was initially controlled with the surgeon's finger and then a sponge stick, which is always a great tool to have in your toolbox. We then were able to isolate that injury by getting control of the bifurcation of the left and right iliac vessels, and just below the renal veins, and then we repaired that initially along a long axis with a running 5-O proline, because it looked like it just wanted to come together that way, and we felt that would be the simplest. But once we were done, we realized we had narrowed the cava down too narrow, and I was really worried about poor flow through there and thrombosis of the cava, and so we actually were able to mobilize the cava a little bit and close it horizontally, which actually when we got done, it looked very nice. About that time, we noted bile coming up from the portal region. Now, so at this point, the liver is not bleeding because we packed it. We've controlled the major bleeding coming from the inferior vena cava, but anesthesia is concerned, and so they're giving fluids and blood while we're working. It's important, as we'll talk about at the end of this case, to kind of have a flowing conversation, a dialogue with your anesthesiologist about resuscitation needs and changes in vital signs while you're operating, so you know, can I continue this operation, or do I need to change this to a damage control operation? At this point, we identified two colotomies that had a little bit of stillage that we had controlled, and we stapled off a colon, proximal and distal of those, and just removed that segment of colon with the plan of leaving the colon in discontinuity. We found four enterotomies along about a 10 centimeter segment, and then we resected that piece of small bowel again with the GIA stapler and just left that out in discontinuity as well, so essentially converting this to a damage control laparotomy at this point. There were four duodenal injuries identified, and right behind blood vessel injuries, duodenal injuries are things I do not like. They're hard to manage. You can throw them in with a pancreas injury, and they can be very difficult patients to manage, but in this case, there were more four small injuries to the duodenum from the projectile. We repaired these all primarily because there was no combined pancreatic injury, and the injury itself was not a very large duodenal injury. There was no reason to consider an exclusion, a duodenal exclusion, or any other approaches that you use for more catastrophic duodenal injuries. If you have 75 percent of the duodenal wall injured, you should consider doing some type of a duodenal exclusion procedure. We then elected to close, and by this time, the bowel had become pretty distended, in part because of the cable repair. During that part of the case, we had the bowel rolled up completely, and we were given a lot of fluids during the case as well, so it's kind of a combination effect, but the bowel was distended. It was left in discontinuity. As I said, we packed the liver, repacked the liver, and then we placed Snap Thera on and went back to the pediatric intensive care unit. So, looking at the fluids that the child was given, he got about two liters of crystalloid, which is quite a bit, you know, over 220 cc's per kilo during the case. This is a small kid. I believe he was about 17 kilos. 600 cc's of PAX cells and 600 cc's FFB, so we're doing pretty good on our one-to-one, but I don't see any platelets listed. Had about a 500 cc blood loss, which was likely an estimate, and 150 cc's urine output during that time, so that's a lot of fluid shifts in a short period of time, and there was some resuscitation needed to be done because we had lactate at 4.4, but really during the case, he never was significantly hypotensive, so we may have overshot a little bit on our fluid resuscitation here. I think that did contribute to us not being able to close his abdomen. However, we knew that we were going to have to come back anyway because we left him in discontinuity, and I had to remove that pack and look at the liver again, so it wasn't like I would not have put the naphthera on him anyway, but when you commit a patient to this, you're committing them to a long hospital stay and a lot of fluid shifts and a lot of operations, so just kind of keep that in mind. So the surgeries, this child had X-lap on the 9th, had a wash out on the 11th. On the 13th, went back and had an end colostomy because the colon got pretty big by this time, and a small bowel was repaired, but the naphthora was replaced. We then washed him out again, got him a partial closure three days later, and the next day closed his fascia completely, and then came back about five days later and closed the skin and subcutaneous tissue, so he underwent five additional operations after his initial X-lap. This child did well, but was taken out of custody of the family he was living with, and is under the care of another surgeon now in Nashville, living with a foster family there. So things that I would be concerned about on this child post-operatively, because the caval injury would be clot formation in the inferior vena cava, embolus formation from that, which did not happen in this child's case. In addition, worried about initially post-operatively a lot of fluid shifts. The apthera device is great for allowing the bowel to kind of go back down and lose its edema, but it also can quickly cause a lot more fluid shifting than you'd normally see in a post-op patient, so you have to kind of be ready to address that as it's happening. At the same time, we're not going to over-resuscitate him because we really want to get a little bit of that fluid off quick as we can so we can get that apthera device removed. The longer that wound stays open, the harder it's going to be to get it back together, and then once the enterotomies were repaired, watching those to make sure those heal okay, watching for return of bowel function, no sign of a leak or anything like that, and then the duodenal injury, which obviously, like I said, that makes me more scared than anything. So we took some time post-operatively awaiting return of bowel function before we really started feeds, but once, you know, like kids always get better, seem like a little bit quicker than adults do, once we had good ostomy output, we went ahead and started feeding at that time, and he did do well from that point on. A few questions about this case so far. It seems to have stimulated some conversation. One is, did you use some sort of massive transfusion protocol for this patient, and then sort of related to that, do you use Rotem or thromboelastography to dictate or to guide what sort of blood products that you use? So that's a good question. We don't use, we use the tag in an ad hoc basis. We don't use it to guide therapy currently. We do in other instances, but not so far in our trauma patients. It probably is something we should start doing. In this case, we did not activate MTP, but we did in the case that follows, and I believe that was the extent of your questions on that. Anything else? There's a question I see says in the chat, how long before you can feed the patient did you have to TPN? I'll be honest with you, I don't remember if we did TPN on this cow. I would have waited about a week before I started TPN, but I'm thinking we did start TPN on him after a week, because he was going back and forth to the operating room, so we would not have been starting any enteral therapy on him during the first 10 days of his care, just because we were in and out of his abdomen so many times, but normally we would not start TPN until after about a week. Was TXA used? No, TXA was not used this patient. Any other questions? And then one question related to this, there's some questions we can probably leave till after the last case, but for in liver injuries, what are your thoughts about the use of IR or embolization? So yeah, our embolization, I've used it in blunt liver injuries where it just seems like it's bleeding from everywhere, and if you can get the liver packed and get them back to the ICU and warm them up, and I've taken a couple of kids to the IR suite and embolized bleeding from the liver. In fact, I have one kid that we just embolized just about every arterial vessel because the child was going to die and that kid actually wound up living, and amazingly the liver functions did not go through the roof and he did okay eventually, but it's not normally very helpful. I only do it in a kid that I really don't feel like I have much other option. I do think it's important to get them operatively packed and try and approach them that way before you go to our suite. So if you've got someone with a blunt liver injury that's bleeding significantly, go in the operating room, pack in that, and then warming them in the ICU because usually they're going to be very cold and so nothing you do is going to help before you go to our suite, I think can be helpful. I have one more question. It says after a week with the duodenal injury, if you have a patient with a high tube output, do you attempt to clamp the NGD? Yes, so I do something that some of my partners don't like. I'll actually put the NG tube on gravity. I'll oftentimes check the NG tube because it seems like NG tubes will tend to migrate a lot and they'll be migrated past the pylorus and you'll be getting a spuriously high output. So if I have a repair duodenum, the injury is stooling, but I'm getting a bunch of bile back in my NG tube, I'll just take it off suction and see how it does to gravity or clamp it and check the output every four hours. And if I'm still concerned before I feed them, I'll just do a study and make sure there's not a stenosis because these injuries sometimes can cause more surrounding scar tissue and at three weeks you're really going to see a lot of two to three weeks you're going to see a lot of contraction of scar. So it could have been a stenotic problem more than a lack of healing or a leak. So I'll do a study through that duodenum just to make sure it's open before I feed them if I have to. Okay, this is one of my passions, duck hunting, and that's a good picture you can make a muddy rice field look like during duck season. So I'm going to move on. The last case I think, let's see. Okay, that last case. So case number three, seven-year-old gunshot wound to the right arm and chest, and this is LN. So this is another child who is at home minding his own business, literally sleeping. Multiple gunshot wounds occurred in a drive-by shooting into the home, through the walls, into the home. He was found down and his dad sweeped him up and brought him to the emergency room. When he got to the emergency room, he was lethargic, but he was making some noises. Now, he had no head injury, so why do you think he was a lethargic? Because he was in significant shock. His heart rate was 144, blood pressure was 80 over 53, temperature was 36. He was small, only weighed 22 kilos, and GCS was deemed to be a 10. His exam, again, head was fine. He had weak pulses. Respirations, he had decreased breath sounds on the right. As abdomen was distended, he had an entry wound on his right chest in the mid-axillary line, about the 10th rib or so. He had an entry and exit going through his right upper arm, where literally you could see through the hole. It was so big, with obvious bone missing. He had no palpable pulse in his right wrist, and as I mentioned, the entry wound in his right chest. Remaining exam was negative. His labs, his electrolytes were okay. His liver functions were elevated. His lactate was 5.6, so he's a little bit more shocked than the previous child, as we could tell by his neurologic function. His H and H is 8 and 25. His blood gas looks good, but it said he's got a base deficit or not. So again, just more evidence of shock, and his PT, PTT and INR are all out. Again, just more evidence of the same. He's been bleeding a great deal. He's lost a lot of volume and now he's starting to get a little coagulopathic. So this is his initial chest x-ray and what you see here, you really have to look over here under the words to see his arm injury, but you can trust I'll show you a picture in just a minute. It was a big missing piece of bone over there and despite the fact that he didn't have any powerful pulses, we got a little Doppler signal on his right finger. So he amazingly had some collateral flow there from something, but we were concerned about his arm. He had had a chest duplex because of a right-sided pneumothorax. If you see there on the chest x-ray, he's got a pretty significant pulmonary contusion and then you see some shrapnel in his abdomen. So at this point, you kind of think about what your approach is going to be and although he does have an ischemic right arm, he's still bleeding and he needs resuscitation, but he needs a laparotomy as well. So we opted to go to the operating room. Again, the injuries he had from outside in, he had a comminuted humerus fracture, brachial artery and vein transection, which we identified in the operating room. Interestingly enough, his artery was no longer bleeding because as you know in children, if they're completely transected, they will oftentimes spasm and thrombose. We did wrap it back up to control kind of the constant ooze that was going on. His nerve, both radial and ulnar nerve, were transected and he had a 15% injury to his median nerve. We didn't clearly identify that at that time, but that did get identified throughout his surgery. A right hemoneumothorax, which at this point was stable, he had two diaphragm injuries on the right. The right lobe of his liver had a very large hole in it that was actively bleeding. He had a common bowel injury at the confluence of his left and right duct and he had a transverse colon injury in two different spots. So the timing of repair and the approach that we took was we opened his abdomen. Immediately, the liver looked like a very impressive injury and so we packed that, but his packing failed. Once we started looking around at some other areas that we were trying to repair, we noticed blood pulling back up and went back to his liver again and we removed his pack, tried to repack him. It did not work. So we just took a big old PDS and did basically a horizontal mattress stitch in his liver through the hole and that pretty much controlled the bleeding. We repacked it too also, but that did the trick. We fixed his diaphragm injuries real quickly. His colon was controlled basically by some clamps and we repaired that and then we noticed some bowel leaking from around. So at this point, we've got his bleeding from his liver pretty much stopped. The diaphragm is repaired. The colon is controlled and so he's really not bleeding at this point anymore. So anesthesia has got a chance to catch up. We're just kind of going around seeing what other injuries he has and we see some bowel coming out from his porta heptus area and we've identified a bowel duct injury. Again, this kid is only seven years old, I think, at the time. Bowel duct injury at the bifurcation that had taken out basically the medial wall of the left and right bowel duct with the lateral wall still intact and the middle of the V where those two ducts joined was missing. So you essentially had the left duct and the right duct connected to the common hepatic duct by the lateral wall only. There was a bullet fragment that was also sitting right in the crotch of the portal vein, but thank God the portal vein had not been injured or we'd be having a different discussion, but it was just sitting there. So we removed that bullet fragment and thankfully nothing started bleeding. We then packed that little bifurcation area, worried that it could start bleeding, and then we identified, we called vascular surgery at this point because we really felt like any other operation is going to take too long and we need to dress his arm. He got a unit of blood in the emergency room during this operation and 800 cc's of crystalloid. In the OR, he wound up getting five units of blood, four of FFP, two of platelets, one of cryo, and three liters of fluid. Now he was in the operating room for quite a while because I actually went and took a nap while vascular surgery was addressing his arm at this point. So we had orthopedics, we had hand come in and see him, and we had vascular surgery come and see him. So his right humerus injury you can see a little bit better now. The vascular surgeon was able to revascularize him in two and a half hours time with a vein graft that he harvested from the sapton's vein. The orthopedic surgeon then came in and took a little bit longer than I thought he would, but was able to stabilize the fracture, identified the nerve injuries that were there, tagged those with some nylons for a repair to be done later, and as you can see, here's a picture of the fracture repair, and then there's a picture of the vascular repair that the patient had. So then we came back in the operating room, and although I did take a little short nap, I also called a bunch of people on the phone and asked them how they handled a bile duct injury in a seven-year-old. Nobody that answered the call had a good answer, and so I was given lots of lots of options. You know, somebody told me just ligate the duct to control the bile leak, allow it to dilate, and come back and fix it another time. Another surgeon said that they would do just a hepatico-ruin-y, hepatico-jejunostomy right now, and so the option was do something definitive now or wait, do something later. Well, this child was not bleeding. He was completely stable at this point. All those major vascular injuries have been repaired, and so we're just left with oozing from his, excuse me, pouring out a bile from his bile duct. So we did have some time to do an operation of some that would take a little bit of time, and one of the surgeons I spoke to, which is the one I wound up going with, said that I should go ahead and fix him now because I'll never have a better chance to fix this child than I will right now, that the view will never be better, they'll never have less scarring. So we decided to go and try and repair this duct. Now, we first placed some Bates dilators into the duct to see what size duct we were dealing with, and it was one millimeter in size, which is very small, and nobody makes a t-tube that small. So we took a 2.7 French, which is less than a millimeter in size, Broviac catheter, and cut it in two little pieces and put one up the left duct and one up the right duct, and then sewed that duct back together using the tissue available to us with those small, quote, biliary stents that we had made ourselves in place. It's hard to see on that image, but if you look on this image, which is blown up, you may see a little a little wire right there, and that those are two stents that are going through the repair that are sitting down into the main duct. I did wind up getting an interventional gastroenterologist to get involved in this case later, and he asked, he told me I should have left, I should have put the ducts in long enough to have them hanging out into the duodenum, which would have made his job easier to go and pull them out later, and that was a mistake. I didn't want to make them that long because I was worried it was going to get an infection and maybe a bile leak with an infection, but that was something that maybe I should have done differently. But at any rate, I need to go back one slide, yes, he wound up having a big biloma to address one of the questioners previously. He did have a blush, which we thought initially was maybe a AVM, but it was actually a biloma in his right lobe of the liver where the where the bullet track had gone, and so we had watched that, but elected not to really drain it and address it because we had such good flow distally, and so we wound up doing this HIDA scan later to make sure he didn't have a leak, which he did not, and then I brought in and did an ERCP at a couple of months post-op to get those two stents out and to check and make sure there was not a stricture or stenosis, which I was sure there was going to be, and to the surprise of all of us, the stents had actually fallen out and passed, and he did not have a stricture or stenosis. He did still have the biloma, a little bit of a biloma that was visible on the ERCP, but did not need to be addressed. We just watched that. So that child wound up doing remarkably well. His right arm function is not back to normal. He's had it reconstructed. The nerves have been reconstructed once. He may have to have an attempt at that again. His bone is completely healed. He's unfortunately right-handed, but he's young enough to become a left-handed dial-up person. His bile drainage has always been good. The things to watch that, you know, I had the nurses really paying attention to on this case, we're looking at his bilirubin, looking at his urine output, and neurovascular checks on his right hand, obviously, because of the vascular repair. But, you know, again, after that long operation, we did not have to change this into a damage control surgery, because his fluids were managed a lot better. We didn't have to eviscerate all of his bowel, really, to do a long operation like I had to do in that inferior vena cava repair. So I think those two things contributed to the fact that, you know, we didn't over-resuscitate him, and it was a longer operation, so it gave anesthesia time to be a little bit more careful with their resuscitation. We were following our massive transfusion guidelines, and once we got him corrected and felt he was doing well, we kind of just eased off on that, did not over-transfuse him either, which can be a problem when things are a little hairy, and it's chaotic in the operating room, where someone drops their pressure, and you slam them with so much blood, you wind up with a hematocrit of 50 when you get back to the PICU. We've seen that before. So to summarize kind of the, I think, the important points of this talk, any gunshot wound, especially in a young child, will cause tremendous injury due to the energy transfer, but high velocity injuries, which we're seeing more and more of, unfortunately, can do a lot more damage, mainly because of the speed of the bullet. It's not always about the size, but the speed. They can go through doors and walls and still cause significant bodily injury, and they tend to be multi-compartmental, so it's not unusual for a bullet that goes into the abdomen and goes down, let's say, into the leg and causes a vascular injury of the lower extremity or through the chest and the abdomen or through the arm, chest, and abdomen, as in this case, still with plenty of force to do a lot of damage to the abdomen and the chest. Common bile duct injuries, which I'll be honest with you, I haven't had very many of, but, you know, sometimes the best, the thing I learned about this case, in this case, sometimes the best chance to get a good repair is right then, and I think that it's a mistake. Sometimes we let damage control become our primary approach for surgical patients with surgical trauma patients, and it should not really be the primary approach. It only should be used when necessary, when you need to resuscitate a child to get them better before you do their definitive operation, and then, again, resuscitation goals are all about restoring tissue perfusion, which is reversing lactic acidosis and replacing the products that are lost, and a lot of times, if the product's lost, we'll restore tissue perfusion, then you don't have to give all that crystalloid, which is obviously a lot better off for the patient and for fluid management problems in the future. I'd be happy to take any more questions or if you have about that case or anything else. Kim, you see anything? There's a couple of questions in the Q&A. One to do, again, with TEG utilization. Do you use it at all in your institution or especially in that this last case with all the resuscitation? So, yeah, we do use it in our institution, mainly for ECMO kids. It takes a little while to get our tags back, and so in the operating room, a place where I've used it in a trauma patient would be more of a blunt trauma patient where I'm trying to get bleeding stopped and I'm doing a lot of waiting at the bedside, watching and transfusing products, but our turnaround on our TEG just we're not there where we can use it as quickly and get a good answer quick enough to act on it. So that's why it's more common that we use it in our ECMO patients because a lot of those decisions you don't have to make those immediately. So we usually use PT, PTT, and INR in the operating room, and we try to maintain one-to-one-to-one. That's made a huge difference, I think, and then, of course, we just we're watching what the patient's doing too, and then warming the patient is another key because a cold patient, no matter how many clotting factors they have, will not stop bleeding. Another person asks, have you had to deal with fistulas following damage control apparatum and what are your suggestions to best address that complication? I have not had to do with enteric fistulas, which I'm assuming what you're talking about. One of the best tricks I've ever seen for dealing with an enterocutaneous fistula is to use a vac sponge and you put and put a feeding tube or a red rubber catheter into directly into the fistula track, and then you vac around that so you control the leaking around that tube, and it was Richard Miller at Vanderbilt who's now somewhere else. I can't remember where he went, maybe Colorado. Adult trauma surgeon who described that in a meeting, and I've used it a few times, and it works great, and basically the vac sponge goes around the tube. The tube itself is in the fistula, so most of the stuff is draining through the tube, and then you put the vac sponge adhesive on so that it goes all the way up to the tube, and of course you kind of wrap it around the tube, but the tube is draining enteric contents. Your vac is only sucking out what's leaking, and so that allows that to close over time, and you slowly decrease the size of the red rubber catheter, and then you go to a smaller catheter, and eventually, sometimes, hopefully, those will close up, but that's the best trick I've ever seen for enteric fistulas, but I haven't had that problem. I try to get those sponges out early. I don't leave them in the abdomen very long, a day or two at most. It's an interesting question. In the issue of retained bullets or fragments, there has been talk about lead content being an issue, so do you recommend checking lead levels in those kids afterwards? I don't know. I've never checked the lead level in those kids. I would have to have someone send me a paper on that. We will try to get the bullets out if they're obvious or if I can get to them pretty easily, and the police are always interested in that, and I want to do the best I can to help have the perpetrator get taken to justice, but I'm not in those. We've left them in. I haven't checked lead levels, so I'm not sure. We do take a lot of projectiles out later on, though, that are kind of sitting in the subcutaneous tissue. I don't force those patients to keep those. I mean, if they're bothering them, I take them out. And then the only question I see right now that's left is a pre-hospital question, so from a pre-hospital standpoint with an open gunshot wound, does packing with regular gauze versus hemostatic gauze make a difference? I've had a couple of cases where using hemostatic gauze, I think, may have saved a life, combat gauze and stuff like that. I mean, if it's bleeding, actively bleeding, putting combat gauze on there, I think, is a great move, and we've had some EMTs that have done some service and are confident in using that, but I wouldn't put it on an evisceration. You really just need kind of to wrap the bowel up with pressure, and most of the bleeding is going to be minimal. I mean, the first evisceration I showed you came from 125 miles away, so pretty good distance, and still when they got here, they were not in shock. But if you have a wound that's just bleeding, get to where it's coming from, putting combat gauze and then wrapping something tight and even placing a tourniquet if you can is, I think, a great idea. Those are all the questions that I see right now. Oh, there's one more, one more. Somebody just asked, do you have protocols in place for EMS to give blood to the children en route? We don't. We don't have blood in our, our EMS providers do not have blood in there, in the ambulance. That, that will probably come with the adults changing their approach to that, but that's not here in Memphis yet. Good question, though. All right. Any other questions that people have, feel free to put them in the Q&A and chat and we'll try to get back to you. Thank you, everyone, for attending this lecture. It was fantastic. Thank you so much, Dr. Eubanks, for this great talk. Thank you.

High Velocity Gunshot Wounds

Pediatric Population

Dr. Trey Eubanks

Resuscitation Goals

Operative Decision Making

Case Management

Resuscitation Strategies

Collaboration with Specialists

Trauma Management