Good morning. My name is Britt Christmas. I am the Associate Medical Director of Trauma at Carolinas Medical Center in Charlotte. Also serve as the co-medical director for pediatric trauma. Currently on the board of the Eastern Association for the Surgery of Trauma as treasurer and pleased to be on the board of TCAA as well. So on behalf of everyone here, we'd like to thank you all for attending this morning. As you mentioned, we're going to adjust our schedule a little bit. So we're going to start off with penetrating trauma, which I'm sure everybody in this room gets a good taste of, right? If you're trauma centers like mine, we've seen our numbers go up and up every year, almost to the point of a 25% tune in the last two years. I have nothing to disclose as it pertains to this presentation. Objectives are to understand the difference between high energy and low energy penetrating trauma, to better understand some ballistics of firearm entries, and to outline some resuscitation and diagnostic strategies. For many of you in the room, how many surgeons do we have in here this morning? So we're clearly in the minority of the people in the room. And a lot of times you all are in the trauma bay and you see us and we make a decision and the goal of this is maybe give you some quick points on, oh, so that's maybe why they're doing what they're doing and what they're going to see on the other end. Of course, penetrating trauma, I'm going to go through this. I think we've got 25 minutes and we've got books written on this entire subject. So we'll start off with low energy. You know, knife wounds, stab wounds, ice picks, really what's the choice of cutlery whenever these patients are coming in? The important thing to consider in these is what's your depth of penetration and number and location of wounds. That's going to kind of raise, lower your suspicion of your injuries. Then the other thing we want to know is this a stab wound or is this a slash wound? And I can tell you even some slash wounds, I have seen some box cutters do some amazing things. And you want to identify your external injuries. As we all know in modern times with the Stop the Bleed campaign, things we can do in the field, in the trauma bay, compression, tourniquets, suture, whatever we have to do to control hemorrhage. And I always love to tell everybody holding compression is not holding pressure and then looking at it every 60 seconds. If it's really bleeding, you hold pressure, you keep pressure until you're somewhere where someone can really do something about it definitively. And then what internal injuries do you suspect based upon the location? Well then we start getting into the algorithm. Is this a local wound exploration versus further imaging versus we're going straight to the operating room? Or maybe just emitting them and observing them for 24 hours. So these are all things that kind of come into the location and mechanism of these injuries. And for us, one of the big things we look at is what are the regions of the abdomen and where are these wounds located? This is going to kind of determine how we, you know, how we first start to approach it. And if you look at your strategies for stab wounds, anterior thoracobdominal is a little different than anterior abdomen, which is different from back and flank wounds. So anterior thoracobdominal wounds, you're worried about pneumothorax, hemothorax. So you're getting a chest X-ray. But what's the other thing we're worried about? Diaphragm injuries. Well, as we all know, CT scans aren't perfect at getting that. You don't have a great diagnostic test for it. So are these people that we're concerned enough that you need to take them to the OR, do a diagnostic laparoscopy? If I've got a left-sided stab wound, a little more hypervigilant there because I can get herniation of colon, stomach, et cetera. But if I've got a right-sided, I may have my liver set up against it and it doesn't cause a problem. So even the side makes your approach a little different at times. Anterior abdomen is really where you start getting into, do I do a local wound exploration, CT scan, or do I just observe them? And so that's where you are. But this is in an area where you're not as worried about diaphragm injuries. You're down lower in truly central abdomen, whereas you get back and flank, you can do your fast looking for hemoperitoneum, but not reliable. You're looking at a retroperitoneal injury potentially. So these are the ones, do you need to get a CT scan? Do you need to get rectal contrast because you can have a retroperitoneal colon injury that you're not going to pick up otherwise? So a few things that our minds are always thinking and working as these patients hit our trauma base. Then local wound explorations. Let me be very clear on this. A local wound exploration is not taking your finger and sticking it in the hole to see where it went. It's actually prep, drape, extend your incision, look and see, did it truly penetrate fascia? Did it not? What direction did it go? And this can be done, local anesthesia in the emergency department and prep it, drape it, last thing you want to do is you find out it's negative and they come back in six days pouring pus out of the wound that you just explored. The other key to this is it's not sticking your finger in the hole and trying to, you know, just get down and go, oh yeah, it didn't hit anything. One, you'll fool yourself and two, you're going to get into a situation where you're going to knock some clot off and do something bad at some point. Laparotomy. Indications for laparotomy in patients that are hemodynamically abnormal, especially if I'm hemodynamically abnormal, positive ultrasound, we're going to the OR. Pre-air, peritonitis, overt evisceration that you're going to have to put them back together anyway. And the reality is early operation is usually your best strategy for gunshot wounds. I know there's been some literature of people that, you know, have described being able to watch certain gunshot wounds, but, you know, 99 times out of 100 I get an abdominal gunshot wound that I know enters the abdomen, we're going to the OR. And then in that, you know, that depends, if they're perfectly stable, worried about a bowel injury, most of the time this is exploratory laparotomy, if your laparoscopic skills are very good and you're comfortable, you can do a diagnostic laparoscopy. We had one of these that we did in the last week. We look and go, what about these wounds? Clearly you got penetrating flank injury there, it goes, what are you going to do with that? Or the evisceration over here in the picture on the right. Now some people will look and say, even with the eviscerations like this, your incidence of bowel injury is maybe 50% or less. Can you just tuck that back in, close the hole, watch them, and maybe they go home the next day? Or if you're not comfortable doing that, what are most of us doing? You're going to laparotomize them and see what you get whenever you get into their belly. What about this? I mean, that's a no-brainer, right? But with a wound like this, I'm thinking, you know, this could be colon, spleen, kidney, you name it, anything on that entire left side. What about this one? Anybody in the room going to take the knife out of their skull? Yeah, no. If an object is impaled, leave it where it is. And this is one you can see goes to the OR, and ultimately that's how deep it was into the brain. So I think this is a great picture that vividly shows you do not remove impaled objects. You take that out of the skull, next thing you know, you've got a massive hemorrhage and a dead patient. So knife wounds are easy, right? What about gunshot wounds? Factors affecting the appearance of your gunshot wounds, type of bullet, integrity of bullet, your dynamics, and distance of gun from the victim. And the thing to remember, I would assume nobody or very few people in here are true ballistics experts, so the thing, whenever you see gunshot wounds, describe the wounds. Don't call them entrance wounds, don't call them exit wounds. You're going to look and say I've got a wound here, a wound here, number, location. Now that being said, there are some things that will tip you off as to the range from which the shot occurred. Right here you can see this is a contact wound. You've got basically burns from the weapon itself against the skin. What about that one? So that's gunpowder stippling where the residue is actually, you can see all around the wound and the skin. So a few feet or less. What about that one? These are the ones we see farther away. You don't see any gunpowder residue or burn marks from a weapon. What about this? If you see this, this is typically what you would call the execution style. They have stuck the muzzle right up against the skin and you can see the stippling where the bullet hit and caused basically the skin to expand, explode. So high energy bullets or other ballistic weapons and then you get into a difference with even handguns, rifles versus shotguns. So gauge, diameter of your shotgun barrel. Anybody know how they determine gauge? So basically this goes back to the old days, that gauge of a shotgun is determined by the weight of a spherical lead ball that would be placed within that barrel. And so if it's a 12 gauge, that lead ball would weigh one twelfth of a pound. If it's a 20 gauge, it would be one twentieth. So when you hear these gauges, that's what it means. Bullet calibers are actually bullet diameters measured in inches. So 22, 45. The thing to remember is 22s and 9 millimeters may bounce and adjust their trajectory, whereas a 45 usually continues in a straight line. It kind of goes to them and through them, if you will. And then you get into the cavitation. These are pressure waves produced by damaging, that are damaging distal to the path of the bullet. And if you really think about it, the real damage comes, it's kinetic energy, right? Energy is neither created nor destroyed. It's always just converted. So the amount of damage you get is dependent one half the mass, but by the velocity squared. So if you get a higher speed, higher velocity bullet, then the amount of kinetic energy displaced is actually squared by the amount of that speed. So a small, fast bullet will actually cause more damage than a large, slow projectile. So if you look at your different calibers, so 22 does 170 joules, and then 38, 325, and then you start getting into the 223s and 762s with 1550 and 3500. So clearly high power, high velocity, and it's an increase by the square of that velocity. And so everybody's seen the Fackler gels whenever you go, and if you actually look and you calculate the temporary cavity diameters, you can see a 22, maybe four to five centimeters area surrounding the permanent path, all the way up to a 762 where you can get 17 to 23 centimeters of blast effect from those injuries. So even though you see a bullet, it's important, was it a handgun, was it a rifle, and exactly what kind of ballistic was it? And this is what the gel looks like in a brain. So clearly you've got the path of your bullet, and you can see the cavity created as it travels through human tissue. What about this one? So you see the hole, and looking at it on the outside, but look at that blast effect. Well, that's not a bullet that was that big that went through. That is the blast injury created by the bullet that went through to the bowel. So shotguns, if you look at them, you have three different types of shells, bird shot, buck shot, and slugs, and one thing to really remember here, if you look at the x-ray on the right, if I see that x-ray, and you see all those pellets are kind of grouped, that tells me that it was a closer proximity. The wider the range of the pellets on your CT scan, the farther away they were. It had more time to scatter. If I see something like this, this was a pretty close range injury, and the thing to keep in mind when you look at these, if you see that arrow up there on the patient's chest, what is that? Close range shotgun wound, you have to worry about this, the wadding that blasts and pushes all the pellets out. If it's close enough, that will actually get blasted into your wound, and as you saw on the previous film, that doesn't show up on x-ray. So if it's a close range wound, odds are you're going to have to debride skin, muscle, et cetera, but look for that wadding, because the last thing you want to do is leave a piece of plastic in your patient. So now we'll get into some of the workup and the time we have left, and so your assessment of penetrating trauma, like everything else, you start with your ABCs, and these days it's a controlled resuscitation. We'll mention that here in a second. And then during your tertiary survey, you want to make sure you mark every injury site prior to x-ray and know where all these are. I want to know shots fired, type of weapon, what was the length of the knife, and then you're getting into your planning. Complete exposure. You've got to cut all their clothes off, look in every single orifice, all crevices, note the number and location of each wound. This is when you start getting worried. If I've got three wounds and I don't see a bullet, say I've got three wounds in the chest and I don't see a bullet on chest x-ray, I'm hunting. I have an odd number. One may have gone through and through, but where is that other bullet? I've got to prove that it's not in there. So you want to look and look for an even number if you think they're through and throughs. If you've got an odd number, then you better chase it because the other bullet may be somewhere else you don't expect. I've seen a small caliber GSW went into the groin, went into the femoral vein, and actually traveled up to the heart. And it's, you know, some bizarre things. They go strange places sometimes. So resuscitation. Aggressive IBD fluid administration to reach normal attention is discouraged. You want to try and keep them on the hypotensive side, systolic pressure 80 to 90, get them somewhere because the last thing you want to do is blow the clot off in these penetrating wounds. In most of our places now, you have massive transfusion packs on ORs that are six units pack cells, six FFP, and then an apheresis pack of platelets. Intensive or emergent laparotomy, I mentioned earlier, particularly hemodynamic instability. And if I've got a, you know, penetrating trauma, hemodynamic instability, I'm going to explore. Don't remove impaled objects and then try and know what the caliber or what the kind of weapon they were shot with. Thoracic injuries. Things that are going to tip you off, make you move a little faster. Tachypnea, respiratory distress, hypoxia, tracheal deviation, of course. And so you're going to get your chest X-ray and you'll see if you've got something that needs to get drained. And then what about this wound? So open pneumothorax. These are the ones that you're going to close on three sides because you look, everybody thinks, oh, they're going to die of a tension. It's actually a ventilation problem. That's what kills these patients. So you need to, you know, get them in. You still put a chest tube in and get them to the OR to address this and fix it as fast as you can. Tension pneumothorax. These patients are in shock, distended neck veins, absent breath sounds, hyper-resonance. We all know it's hard to hear in the trauma bay. And I intentionally put a picture up here because guess what? We live by the thought that you should never have a chest X-ray that shows tension pneumothorax. You should be able to diagnose this clinically and do something about it right away. So if I sat up here and showed you a chest X-ray, I'd be being a hypocrite because I don't want to see that chest X-ray. I want to have it solved before I see that X-ray. Massive hemothoraces. Of course, this is a little different. You're going to have flat neck veins because all the blood's in their chest. These patients are going to be in shock. And what you need to do is restore their volume, get a tube in. And if you get greater than 1,500 cc's out or greater than 200 over the next three hours, you're going to the OR for thoracotomy. Cardiac tamponade. We'll see this. Can diagnose it on ultrasound. And this is very similar to the tension pneumothorax. Extended neck veins, muffled heart sounds. And you're going to see it on ultrasound. This goes straight to the OR. For us, pericardiocentesis is not the way to go. I'm packing this patient up. We are going and that's, you know, those. We now have ultrasound. We can diagnose this quicker and move a little faster. And we should. Resuscitative thoracotomy. When to consider patients with penetrating thoracic injury arriving in PEA in less than 15 minutes. If they've been greater than 15 minutes out, then what we're going to get back, if anything, is not much. So this is 15 minutes or less before they hit the door and you go. We had a call a few weeks ago and by the time I calculated the time from the patient going down to them hitting our door, it was about 45 minutes. You know, everybody's wanting to scramble and, you know, so when you see a shut it down, that's why. And then these are just our guidelines that have been included in the slide packet just for you to go through reference. We should all have guidelines at our institution as to how we treat these. And it's always good if you can go. I know I love to ask people what they're doing at their shop and take some ideas. So I just included that for your reference as well. Thank you. I know that was a quick trip through penetrating trauma.

penetrating trauma

resuscitation strategies

hemorrhage control

abdominal injuries

thoracic injuries