WEEKLY CASE VULNUS SCHLOPETORUM DM Wylie & DM Ega Consultant: dr. Alders A. K. Nitbani, Sp.B

Identity ■Name: Ms. RS ■Sex: Female ■Age: 8 years old ■No. MR: ■Date of admission: 17th June 2019 ■Doctor in charge: dr. Elric B. Malelak, Sp.BS and dr. Dian, Sp.M

Anamnesis ■Main complain: Vulnus schlupetorum ■Mechanism of injury: A girl, 8 years old, was referred from So’e regional hospital on 17 th June 2019 after got shot on the left eye. The patient was drawing water from the well when her cousin shot her instead of the bird he was aim for. Patient brought to the hospital immediately and the got referred to Johannes Regional Hospital. Patient already went on xx procedure for her left eye on 26 th June 2019 and Craniotomy Exploration procedure for locating and evacuating the bullet on her head. At the moment, patient only complai that she felt hungry. Declining of headache, nauseous, vomiting and seizure.

Physical examination ■General state of health : moderate ill ■GCS : E4M6V5, ■Vital sign : BP : 120/80 mmhg, Pulse : 83 x/s, RR 20 x/s, Spo2 : 98% ■VAS : 4 ■Eye : edema and hiperemis at periorbita sinistra, patient can’t open her eyes. anemic (-/x), icteric (-/x), pupil isokor (+/x), Pupil reflex +/x ■Neck : no lymph node enlargement ■Thorax : chest expansion bilateral simetric, pattern of respiration is abdominothoracal –Cor : s1 s2 single, reguler, murmur (-), gallop (-) –Pulmo : vesicular (++++/++++), rhonchi (- /-), wheezing (-/-) ■Abdomen Inspection : flat, distended (-) Auscultation : peristaltics (+) normal Palpation : tenderness (-), no enlargement of hepar lien, defans muscular (-) Percussion : timpany sound (+) Extremities :warm acral, crt<2 seconds, edema (-/-)

Skull X-Ray (A-P Lat view)

Head CT Scan

Diagnose ■Vulnus Sclopetorum + Penetration Trauma + margo palpebral superior rupture + cornea rupture + sclera rupture

Planning ■Observation of GCS, and vital sign ■Ceftriaxone 2x50mg IV ■Ranitidine 2x25mg IV ■Ketorolac 2x10mg IV ■Tranexamed acid 3x250mg IV ■Pro exploration craniotomy (Neurosurgeon) ■Pro repair rupture repair exploration of the eye (Opthamologist)

Gunshot Wounds Injuries created by medium or high-velocity weapons

Mechanism of Injury

Gunshot wounds

Mechanism of Injury The physical event that caused an injury (knife wound, gun shot wound, motor vehicle accident, etc.)

Velocity Low velocity–knife Medium velocity–handgun, shotgun (generally less than 2,000 feet-per-minute) High velocity–rifle (generally greater than 2,000 feet-per-minute) Body region penetrated Exit wounds Mechanism of Injury: Penetrating Trauma

Wound ballistics (Kinematics)

GSW's : Ballistics Ballistics is defined as the science of the motions and impacts of projectiles Wounding capacity = kinetic energy deposited in the tissue Kinetic energy = mass times ( V1 squared minus V2 squared)* * V1 = impact velocity V2 = exit velocity (it is zero if the bullet does not exit) 19

Factors that contribute to tissue damage include: Bullet size: The larger the bullet, the more resistance and the larger the permanent tract Bullet deformity: Hollow point and soft nose flatten out on impact, resulting in a larger surface area involved. : Wound Ballistics: Medium and High velocity wounds

tissue damage continued: Semijacket: The jacket expands and adds to the surface area Tumbling: Tumbling of the bullet causes a wider path of destruction Yaw: The bullet can oscillate vertically and horizontally (wobble) about its axis, resulting in a larger surface area presenting to the tissue. Wound Ballistics: Medium and High velocity wounds

To what is cavitation (shock wave) related? Gunshot Wounds: Cavitation

Entrance and exit wounds Gunshot Wounds

The wound consists of three parts: Entry wound: Usually smaller than the exit wound Exit wound: Not all gunshot wounds will have exit wounds and on occasion there be multiple exit wounds due to fragmentation of bone or the bullet. Generally the exit wound is larger and has ragged edges. Wound Ballistics: Medium and High velocity wounds

Entrance and Exit Wounds

The wound consists of three parts: Internal wound: Medium-velocity bullets inflict damage primarily by damaging tissue that the bullet contacts; High- velocity bullets inflict damage by tissue contact and transfer of kinetic energy (the shock wave producing a temporary cavity) to surrounding tissues Wound Ballistics: Medium and High velocity wounds

Mechanism of Injury: Penetrating Trauma

Gunshot wound trauma injuries

Head: The skull is a closed space, thus presenting some unique situations: The shock wave has no place to go therefore the brain tissue can be compressed. If the forces are strong enough the skull may explode from the inside out. A medium velocity bullet may follow the curvature of the interior of the skull. This path can produce significant damage Penetrating Trauma Injuries

Punctures/Penetrations (Gunshot wounds)

Thorax: Three major groups of structures inside the thoracic cavity must be considered in evaluating a penetrating injury to the chest: Lungs: Less dense tissue so injuries are generally from the bullet tract and less so from a shock wave. Serious injuries include a pneumothroax or hemothorax Penetrating Trauma Injuries

Thorax: Vasular: Blood and muscle is more dense than lung tissue, therefore it is more susceptible to shock waves in addition to the bullet track. Injuries include damage to the aorta and the superior vena cava as well as injury to the heart muscle. Penetrating Trauma Injuries

Thorax: Gastrointestinal: The esophagus is located in the thorax and may be injured by the bullet track Injuries include damage to the esophagus as well as spilling any contents into the thoracic cavity which can lead to infection. Penetrating Trauma Injuries

Punctures/Penetrations (Gunshot wounds)

Abdomen: The abdomen contains structures of three types: Air filled, solid and bony. Gastrointestinal: The majority of the GI system is located in the abdomen. Most of the GI tract structures are considered to be air filled. Injuries include damage to the GI system structures as well as spilling any contents into the abdominal cavity which can lead to infection. Penetrating Trauma Injuries

Abdomen: Solid organs: The solid organ of the abdomen are very susceptible to direct injury as well as injury from the shock wave. Injuries include direct and shock wave damage to all of the solid organs such as the liver, spleen, pancreas, and the kidneys in the retroperitoneal space. Let’s not forget about the bladder, uterus, ovaries, gall bladder, and major blood vessels such as the vena cava and the aorta. Penetrating Trauma Injuries

Abdomen: Bones: The pelvis is a very vascular organ. Fracture of the pelvic due to a gunshot wound can lead to major blood loss Injuries are generally limited to direct bullet track damage. The bone fragments may become secondary missiles and cause additional damage. Penetrating Trauma Injuries

The ultimate in fragmentation is created by shotgun wounds Shotgun Wounds

Muscles, peripheral nerves and blood vessels, connective tissue, skin and bones: All of these tissues may suffer direct injury or shock wave injuries. Injuries may include: tissue loss, bleeding, and loss of function, Penetrating Trauma Injuries

Open Wound

Rapid Trauma Assessment

Head Neck Chest Abdomen Pelvis Extremities Posterior

Inspect and Palpate for DCAP-BTLS ======== DCAPDCAP Deformities Contusions Abrasions Punctures/ Penetrations ======== BTLSBTLS Burns Tenderness Lacerations Swelling

Assess baseline vital signs. Obtain SAMPLE history. Consider requesting ALS. Reconsider transport decision. Significant Mechanism of Injury

SAMPLE History S=Signs and symptoms A=Allergies M=Medications P=Pertinent past history L=Last oral intake E=Events leading to injury or illness

If No Significant Mechanism of Injury Reconsider mechanism of injury. Determine chief complaint. Perform focused physical exam based on: Chief complaint Mechanism of injury

SECONDARY SURVEY

The Detailed Physical Exam Assess areas examined in rapid trauma assessment plus: Face Ears Eyes Nose Mouth Head Neck Chest Abdomen Pelvis Extremities Posterior

Examine slower than during rapid trauma assessment. Often done during transport. Reassess vital signs. The Detailed Physical Exam

Bleeding and Shock

External Bleeding

Severity of Blood Loss Determined by: General impression of blood loss Signs or symptoms of hypoperfusion

Sudden loss of... One liter of blood in an adult Half a liter of blood in a child cc of blood in an infant...is serious!

Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death! Do not wait for signs and symptoms to appear before beginning treatment! Blood Loss

Internal Bleeding

Signs & Symptoms of Internal Bleeding Significant MOI Pain, tenderness, deformity, swelling, discoloration Bleeding from the mouth, rectum, or vagina Tender, rigid, or distended abdomen

Maintain airway; administer oxygen. Control external bleeding.

Elevate lower extremities 8-12 inches. Prevent loss of body heat.

Documentation

Document scene on arrival Document any evidence noted on scene Document interaction with Law Enforcement, Coroner, or Medical Examiner

Danke Schoen