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To answer your first request for a cite, regarding comparable recovery rates for knife wounds & GSW. Happy reading!
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Authors
Heary RF. Vaccaro AR. Mesa JJ. Balderston RA.
Title
Thoracolumbar infections in penetrating injuries to the spine.
Source
Orthopedic Clinics of North America. 27(1):69-81, 1996 Jan.
Abstract
A detailed review of the TJUH experience and the published literature on gunshot and stab wounds to the spine has been presented. The following statements are supported. (1) Military (high-velocity) gunshot wounds are distinct entities, and the management of these injuries cannot be carried over to civilian (low-velocity) handgun wounds. (2) Gunshot wounds with a resultant neurologic deficit are much more common than stab wounds and carry a worse prognosis. (3) Spinal infections are rare following a penetrating wound of the spine and a high index of suspicion is needed to detect them. (4) Extraspinal infections (septic complications) are much more common than spinal infections following a gunshot or stab wound to the spine. (5) Steroids are of no use in gunshot wounds to the spine. In fact, there was an increased incidence of spinal and extraspinal infections without a difference in neurologic outcome compared with those who did not receive steroids. (6) Spinal surgery is rarely indicated in the management of penetrating wounds of the spine. The recommendations for treatment at TJUH of victims of gunshot or stab wounds with a resultant neurologic deficit are as follows. (1) Spine surgery is indicated for progressive neurologic deficits and persistent cerebrospinal fluid leaks (particularly if meningitis is present), although these situations rarely occur. (2) Consider spine surgery for incomplete neurologic deficits with radiographic evidence of neural compression. Particularly in the cauda equina region, these surgeries may be technically demanding because of frequent dural violations and nerve root injuries/extrusions. These cases must be evaluated in an individual case-by-case manner. The neurologic outcomes of patients with incomplete neurologic deficits at TJUH who underwent acute spine surgery (usually for neural compression secondary to a bullet) were worse than the outcomes for the patients who did not have spine surgery. A selection bias against the patients undergoing spine surgery was likely present as these patients had evidence of ongoing neural compression. (3) A high index of suspicion is necessary to detect spinal and extraspinal infections. (4) Do not use glucorticoid steroids for gunshot wound victims. (5) Conservative (nonoperative) treatment with intravenous broad spectrum antibiotics and tetanus prophylaxis is the sole therapy indicated in the majority of patients who sustain a penetrating wound to the thoracic or lumbar spines.
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Authors
Madiba TE. Mokoena TR.
Title
Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas .
Source
British Journal of Surgery. 82(9):1236-9, 1995 Sep.
Abstract
The records of 152 patients with pancreatic injury treated over a 5-year period were reviewed. The diagnosis was made at laparotomy in all patients. Gunshot wounds, stab wounds and blunt trauma occurred in 63, 66 and 23 patients respectively with mean ages of 28, 28 and 30 years. Multiple organ injury was most common after gunshot wounds. Intraoperative management was by drainage of the pancreatic injury site alone in the majority of patients in all aetiological groups. The rate of fistula formation was 14 per cent after gunshot wounds, 9 per cent after stab injury and 13 per cent after blunt trauma. Death occurred after 24 h in 8, 2 and 10 per cent of patients following gunshot wounds, stab wounds and blunt trauma respectively, and was attributable to other organ damage. It is concluded that gunshot injury to the pancreas may be more extensive than other injuries, but conservative management with surgical drainage of pancreatic injury is justified irrespective of the mechanism of injury.
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Authors
Velmahos GC. Degiannis E. Hart K. Souter I. Saadia R.
Title
Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries.
Source
Journal of Trauma. 38(3):334-7, 1995 Mar.
Abstract
OBJECTIVE: The changing profiles of spinal cord injuries in South Africa are addressed in this study. DESIGN: A retrospective analysis of 551 patients with spinal cord injury. MATERIALS AND METHODS: The cause of injury was motor vehicle crashes in 30%, stab wounds in 26%, gunshot wounds in 35%, and miscellaneous causes 9%. MEASUREMENTS AND MAIN RESULTS: There was a significant shift from stab wounds towards bullet wounds over the last five years. Bullet spinal cord injuries increased from 30 cases in 1988 to 55 cases in 1992, while stab spinal cord injuries decreased from 39 cases in 1988 to 20 cases in 1992. The incidence of spinal cord injuries following a motor vehicle crash showed a declining tendency after a transient increase (28 cases in 1988, 40 in 1990, 31 in 1992). Moreover, the problem of severe septic complications has been investigated and various risk factors for sepsis that might impair the rehabilitation process have been examined. The risk of developing septic complications was higher in gunshot spine injuries (21 cases out of 193) than in knife injuries (5 cases out of 143). The presence of a retained bullet did not seem to increase the chances for sepsis. In seven patients the sepsis was the direct consequence of the retained bullet while in 14 patients sepsis developed with no bullet in situ. Furthermore, the site of the injury (cervical, thoracic, lumbar spine) did not correlate with the abovementioned risks. CONCLUSIONS: Gunshots carry a heavier prognosis. Only 32% of our gunshot cases underwent a significant recovery as opposed to 61% of stab cases and 44% of the motor vehicle crash victims.
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Authors
Degiannis E. Velmahos GC. Florizoone MG. Levy RD. Ross J. Saadia R.
Title
Penetrating injuries of the popliteal artery: the Baragwanath experience.
Source
Annals of the Royal College of Surgeons of England. 76(5):307-10, 1994 Sep.
Abstract
This study describes the management of 43 patients with penetrating injury of the popliteal artery. Of these patients, 33 (76.5%) had bullet wounds, four patients (9.5%) pellet wounds and 6 (14%) knife wounds. Patients with 'hard' signs of arterial injury underwent exploration without preoperative angiograms. There were no negative explorations. Patients with only 'soft' signs of arterial injury underwent preoperative angiograms. Of this group, 75% had positive angiograms and underwent exploration. There were no false-positive or false-negative preoperative angiograms in the group of patients with 'soft' signs in this study. Definitive orthopaedic management of associated fractures followed vascular reconstruction. There was no difference in the short-term patency of autologous saphenous vein graft as against PTFE grafts. Fasciotomy was performed on patients who had arterial and venous injury or presented late. Overall amputation rate was 14% and for bullet injuries 18%.
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Authors
Rothlin M. Vila A. Trentz O.
Title
.
Source
Helvetica Chirurgica Acta. 60(5):817-22, 1994 Jul.
Abstract
Between 1981 and 1990, 105 patients suffering from gunshot and stab wounds were admitted to the Department of Surgery of Zurich University Hospital. There were 17 female and 88 male patients aged 16-74 years (average 31 years) whose charts were studied retrospectively. 44 patients demonstrated gunshot injuries, while 60 suffered from stabwounds and 1 patient had both. The injuries were the result of a crime in 59, a suicide in 33 and an accident in 11 cases. In 2 patients the cause was not conclusive proven. Injuries to the lung (n = 54), the liver (n = 27) and to the stomach (n = 23) were seen most frequently. 45 patients underwent laparotomy, while 16 had a thoracotomy performed. Both thoracotomy and laparotomy were necessary in 10 cases. Complications were observed in 29.5% of the cases. They were significantly more frequent in patients with gunshot injuries (p < 0.0004). Overall mortality amounted to 14.3% (n = 15). Patients with gunshot wounds had a significantly higher mortality rate (p < 0.0005). Debridement and selective closure of the wounds (n = 25) did not result in a higher rate of abscess formation than open treatment (n = 17).
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Authors
Coimbra R. Prado PA. Araujo LH. Candelaria PA. Caffaro RA. Rasslam S.
Title
Factors related to mortality in inferior vena cava injuries. A 5 year experience.
Source
International Surgery. 79(2):138-41, 1994 Apr-Jun.
Abstract
Forty-nine patients sustaining Inferior Vena Cava (IVC) injuries, during a 5 year period were retrospectively analyzed in order to assess those factors related to early deaths. Mean age was 32 and 45 were male. GSW was the most frequent mechanism of injury (59.2%), followed by SW (28.6%) and blunt trauma (12.2%). There were 4 injuries in the supra diaphragmatic IVC, 14 retrohepatic, 16 suprarenal and the remaining 15 were in the infrarenal portion of the IVC. Twenty patients were in shock and 8 were unstable on admission. The liver was the most frequently injured organ in association with IVC and there were also 7 concomitant abdominal vascular injuries. Venorrhaphy was performed in 28 patients, IVC ligature in 5, intracaval shunt in 3 and in the remaining 13, only temporary hemostasis was attempted. Mortality rate was 100% in supra diaphragmatic injuries, 71.4% in retrohepatic, 68.8% in suprarenal and 33% in infrarenal injuries. There was a significant difference when comparing mortality rate in stable against shock or unstable patients on admission (p < 0.001), as well as in those with diaphragmatic IVC injuries compared with all other injury sites together (p < 0.05). Hemodynamic instability on admission was the most important cause of early deaths, and all patients with concomitant abdominal vascular injuries also died.
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Authors
Degiannis E. Velmahos G. Krawczykowski D. Levy RD. Souter I. Saadia R.
Title
Penetrating injuries of the subclavian vessels.
Source
British Journal of Surgery. 81(4):524-6, 1994 Apr.
Abstract
A study was made of 76 patients with subclavian vessel injury. The mechanism of trauma was stabbing in 40 patients (53 per cent) and gunshot in 36 (47 per cent). There were marked differences between the two groups in clinical presentation, operative management and outcome. The group with gunshot injury was characterized by a more immediate threat to life, and a greater need for a median sternotomy and use of interposition grafts. The mortality rate in patients with gunshot wounds was more than twice that in the group with stab injury.
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Authors
Tang E. Berne TV.
Title
Intravenous pyelography in penetrating trauma.
Source
American Surgeon. 60(6):384-6, 1994 Jun.
Abstract
Intravenous pyelograms (IVPs) are routinely used in the workup of suspected urologic injuries. The indications for obtaining IVPs have not been well characterized. This study examined 67 patients with penetrating trauma who received formal IVPs with nephrotomography in the radiology department. Of 35 stab wounds, 19 patients presented without hematuria and accounted for only one positive IVP. No intervention was undertaken in this patient. There were 14 stab wound patients with microscopic hematuria, with three positive IVPs. No intervention was necessary in any of these patients. The two remaining stab wound patients both had gross hematuria and renal injuries requiring intervention. However, only one of the two had a positive IVP, showing a blurred kidney margin. One patient had a pseudoaneurysm of a branch of the renal artery, and the other had an arteriovenous fistula. Of 32 patients with gunshot wounds, 15 presented without hematuria. Of the 15, one had a positive IVP but did not have a renal injury on exploration. None of the other 13 patients in this group undergoing exploration had renal injuries. Of the 11 patients with microscopic hematuria, three had hematomas and one had gross extravasation on IVP. Of the six patients with gross hematuria, three had positive IVPs, showing a hematoma, a renal fracture, and indistinct renal outline, respectively. In this limited study, omitting IVPs on the patients with negative urinalyses would not have missed any significant injuries. We suggest that more study is needed in this area because our present standard may lead to unnecessary expense and delay.
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Authors
Velmahos GC. Degiannis E. Souter I. Saadia R.
Title
Penetrating trauma to the heart: a relatively innocent injury.
Source
Surgery. 115(6):694-7, 1994 Jun.
Abstract
BACKGROUND. The purpose of this study was to examine the mortality rate of penetrating cardiac trauma in a large urban hospital. METHODS. This was a retrospective study over a period of 5 years and 5 months of all patients admitted alive with a stab or a gunshot cardiac injury. RESULTS. There were 310 patients with a stab wound and 63 with a gunshot wound. The overall mortality rate was 19%. The mortality rates for the stab and the gunshot groups were 13% and 50.7%, respectively. In the 296 patients with a cardiac stab wound confined to a single chamber and with no other associated extracardiac injury the mortality rate was 8.5%. CONCLUSIONS. An isolated cardiac stab wound is a relatively innocent injury in a patient at a hospital accustomed to managing penetrating trauma expeditiously.
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Authors
Mock C. Pilcher S. Maier R.
Title
Comparison of the costs of acute treatment for gunshot and stab wounds: further evidence of the need for firearms control .
Source
Journal of Trauma. 36(4):516-21; discussion 521-2, 1994 Apr.
Abstract
Gun control is proposed primarily to decrease the incidence of injury and death from gunshot wounds (GSWs). We hypothesize that decreasing the number of GSWs will also produce significant economic savings, even if personal violence were to continue at the same rate, maintaining the same overall incidence of penetrating trauma. We analyzed charges and reimbursements for the treatment for all patients with GSWs (n = 1116) and stab wounds (SWs) (n = 1529) admitted to a level I trauma center from 1986 through 1992. Mean and median charges were higher for GSWs ($14,541; $7,541) than for SWs ($6,446; $4,249) (p < 0.05). There was a 12% per year increase in the annual number of GSWs (p = 0.001), leading to a disproportionate increase in the annual total charges for GSWs (p = 0.013), compared with SWs. Public expenditures, including bad debt and government reimbursement, increased for GSWs (p = 0.019) but not SWs. Thus, if all patients with GSWs instead suffered SWs, there would be an annual savings of $1,290,000 overall and of $981,000 of public funds from this institution alone. Treatment costs for GSWs are higher than those for SWs and are rising more rapidly, with an increasing amount of public funds going to meet these costs. Considerable savings to society would accrue from any effort that decreased firearm injuries, even if the same level of violence persisted using other weapons.
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Authors
Rizoli SB. Mantovani M. Baccarin V. Vieira RW.
Title
Penetrating heart wounds.
Source
International Surgery. 78(3):229-30, 1993 Jul-Sep.
Abstract
In 3 years, 26 patients were operated for penetrating heart wounds at our institution, the majority between 30 to 60 minutes after injury. Twenty-two patients with a possible heart wound were immediately taken to the operating room for thoracotomy. One patient initially underwent laparotomy while 2 were observed before operating-room thoracotomy. One patient underwent emergency-room thoracotomy. Three patients with no vital signs on admission died, 82.6% of the remainder survived. Stab wounds determined the best survival rate: 94%, whereas for gunshot wounds it was only 50%. Our experience at this Brazilian Trauma Center reveals that delay in reaching the hospital selected the patients, that clinical condition on arrival, method of injury (knife or gunshot), emergency room staffed with trauma surgeons and aggressive operating room treatment for penetrating heart wounds results in a remarkable survival rate. Emergency-room thoracotomy should be reserved for patients "in extremis" or when there is no operating room available.
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Authors
Macho JR. Markison RE. Schecter WP.
Title
Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination.
Source
Journal of Trauma. 34(5):711-5; discussion 715-6, 1993 May.
Abstract
The resuscitation of patients with cardiopulmonary arrest from a penetrating injury of the heart requires emergency thoracotomy and control of hemorrhage. Suture control may be technically difficult in patients with large or multiple lacerations. Emergency cardiac suturing techniques expose the surgeon to the risk of a contaminated needle stick. After we determined that rapid control of hemorrhage from cardiac lacerations could be achieved in anesthetized sheep with the use of a standard skin stapler, the technique was applied in the clinical setting. Twenty-eight patients underwent emergency stapling of 33 cardiac lacerations at our institution from September 1987 to December 1991. Seventy-nine percent (22) of the patients sustained stab wounds, and 21% (6) were injured by gunshots. Fifty-eight percent (19) of the injuries involved the right ventricle, 27% (9) involved the left ventricle, 9% (3) involved the right atrium, and 6% (2) involved the left atrium. In 93% (26) of the patients, control of hemorrhage was achieved within 2 minutes of exposure of the injuries. Both patients in whom control could not be achieved had sustained large-caliber gunshot injuries. Fifteen (54%) of the patients survived, including one patient with two cardiac lacerations and another with three lacerations. Of the surviving patients, two had mild neurologic deficits. No personal contamination occurred related to the use of the stapler. We conclude (1) cardiac stapling is highly effective in the management of hemorrhage from penetrating injury, particularly in the setting of multiple cardiac lacerations; (2) the technique may not be effective with certain types of gunshot wounds; and (3) the use of the stapler for emergency cardiorrhaphy eliminates the risk of personal contamination from a needle stick.
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Authors
Mitchell ME. Muakkassa FF. Poole GV. Rhodes RS. Griswold JA.
Title
Surgical approach of choice for penetrating cardiac wounds.
Source
Journal of Trauma. 34(1):17-20, 1993 Jan.
Abstract
One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.
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Authors
Kaufman JA. Parker JE. Gillespie DL. Greenfield AJ. Woodson J. Menzoian JO.
Title
Arteriography for proximity of injury in penetrating extremity trauma.
Source
Journal of Vascular & Interventional Radiology. 3(4):719-23, 1992 Nov.
Abstract
Arteriography for proximity of injury was studied prospectively at a trauma center. Findings in 85 patients with penetrating extremity wounds were analyzed to determine the prevalence and types of vascular abnormalities seen with these injuries. Ninety-two limb segments were studied for 77 gunshot and 15 stab wounds. Arteriographic findings were positive in 24% overall but in only 5% for injuries confined to major vessels. A 60% positive rate was seen in a small subgroup of 10 patients with fractures due to gunshot wounds. The most frequently injured vessels were muscular branches of the deep femoral artery (59%); the most common injury was focal, non-occlusive spasm (42%). All patients were treated conservatively, without sequelae at follow-up. In this study, the vascular injuries found at arteriography for proximity of injury in penetrating trauma due to bullets of knives, particularly in the thigh, did not require surgical or radiologic intervention.
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Authors
Nagel M. Kopp H. Hagmuller E. Saeger HD.
Title
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Source
Zentralblatt fur Chirurgie. 117(8):453-9, 1992.
Abstract
From 1973 to 1991 a total of 422 patients underwent surgery because of an abdominal trauma. 12 patients had gunshot wounds and 46 patients stab wounds. In a retrospective study the diagnostic and therapeutic procedure and the indication for surgery are analysed. After gunshot wounds of the abdomen we always performed a laparotomy. In 11 od 12 cases we found serious intra-abdominal injuries. Only in one case the laparotomy was "unnecessary", because of a tangential wound without penetrating of the abdominal wall. After stab wounds the diagnostic and therapeutic management was more selective. Indications for mandatory laparotomy after stab wounds were a manifest hemorrhagic shock, evisceration and a still left weapon in the abdomen (n = 22). The first clinical examination was completed by ultrasound or peritoneal lavage. Pathological findings like free intraperitoneal fluid or a positive lavage also were indications for laparotomy (n = 9). The other patients were observed closely, including repeated physical examination. The indication for surgery then based on the development of clinical signs. The time between first examination and laparotomy was never more than 12 hours. 39 patients (84.7%) had injuries of intraabdominal organs. 5 patients (10.8%) had a negative laparotomy. The mortality rate was 3.4%, but there was no death as a result of the selective approach.
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Authors
Saltzman LE. Mercy JA. O'Carroll PW. Rosenberg ML. Rhodes PH.
Title
Weapon involvement and injury outcomes in family and intimate assaults.
Source
JAMA. 267(22):3043-7, 1992 Jun 10.
Abstract
OBJECTIVE--To compare the risk of death and the risk of nonfatal injury during firearm-associated family and intimate assaults (FIAs) with the risks during non-firearm-associated FIAs. DESIGN--Records review of police incident reports of FIAs that occurred in 1984. Victim outcomes (death, nonfatal injury, no injury) and weapon involvement were examined for incidents involving only one perpetrator. SETTING--City of Atlanta, Ga, within Fulton County. PARTICIPANTS--Stratified sample (n = 142) of victims of nonfatal FIAs, drawn from seven nonfatal crime categories, plus all fatal victims (n = 23) of FIAs. MAIN OUTCOME MEASURES--Risk of death (vs nonfatal injury or no injury) during FIAs involving firearms, relative to other types of weapons; risk of nonfatal injury (vs all other outcomes, including death) during FIAs involving firearms, relative to other types of weapons. RESULTS--Firearm-associated FIAs were 3.0 times (95% confidence interval, 0.9 to 10.0) more likely to result in death than FIAs involving knives or other cutting instruments and 23.4 times (95% confidence interval, 7.0 to 78.6) more likely to result in death than FIAs involving other weapons or bodily force. Overall, firearm-associated FIAs were 12.0 times (95% confidence interval, 4.6 to 31.5) more likely to result in death than non-firearm-associated FIAs. CONCLUSIONS--Strategies for limiting the number of deaths and injuries resulting from FIAs include reducing the access of potential FIA assailants to firearms, modifying firearm lethality through redesign, and establishing programs for primary prevention of violence among intimates.
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Authors
Mercer DW. Buckman RF Jr. Sood R. Kerr TM. Gelman J.
Title
Anatomic considerations in penetrating gluteal wounds.
Source
Archives of Surgery. 127(4):407-10, 1992 Apr.
Abstract
A retrospective study of 81 patients with penetrating gluteal wounds was performed to determine if the site of penetration was useful in predicting the likelihood of associated vascular or visceral injury. There were 53 gunshot wounds and 28 stab wounds, including one impalement. The gluteal region was divided into upper and lower zones by determining whether entry occurred above or below the greater trochanters. Sixty-six percent of all penetrating gluteal wounds entered the upper zone. Thirty-two percent of patients with upper zone penetration had associated vascular or visceral injury. Only one of 27 patients with lower zone penetration sustained major injury. The site of entry plays a critical role in determining the likelihood of serious injury associated with penetrating gluteal wounds. Wounds penetrating above the greater trochanters demand thorough evaluation, especially gunshot wounds.
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