CASO CLÍNICO

 

Initial treatment of gunshot wounds. A clinical case report

Tratamiento inicial de heridas por proyectil de arma de fuego. A propósito de un caso clínico

 

 

L. Ramos Xavier¹, M. Alves Crespo², C.M. Soares de Oliveira³, L. de Freitas Baldez⁴

1 1º Teniente Dentista de la Policía Militar del Estado de Río de Janeiro-Brasil. Residente do Servicio Cirugía e Traumatología Bucomaxilofacial de la Marina de Brasil. Investigadora del Departamento de Traumatología e Ortopedia da Universidad Federal do Río de Janeiro, Brasil.
2 Capitão-Tenente Cirurgião-Dentista da Marinha do Brasil. Staff do Serviço Cirurgia e Traumatología Bucomaxilofacial da Odontoclínica Central da Marinha, Brasil
3 Capitão-de-Corveta Cirurgião-Dentista da Marinha do Brasil. Staff do Serviço Cirurgia e Traumatología Bucomaxilofacial do Hospital Naval Marcílio Dias. Brasil
4 Capitão-de-Fragata Cirurgião-Dentista da Marinha do Brasil. Staff do Serviço Cirurgia e Traumatología Bucomaxilofacial do Hospital Naval Marcílio Dias, Brasil.

Correspondence

 

 

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ABSTRACT

Health care professionals in Rio de Janeiro have to gain expertise in a specialty that is becoming increasingly important in the public hospitals of Rio de Janeiro: military medicine.
In the field of oromaxillofacial surgery, the concern of health care professionals is to restore facial aesthetics and function because these wounds cause major damage. In this sense, the initial care of patients with facial gunshot wounds determines the success of treatment this type of trauma. The authors’ intention in this report of a clinical case is to stimulate discussion among other professionals involved in the care of patients who suffer gunshot wounds (GW). The patient studied here was an assault victim who was wounded by a bullet that entered the genial region and lodged in the cervical region. He had a fragmented fracture of the mandibular ascendant ramus and coronoid process. Motivated by the controversy reigning in the world literature regarding the initial response in these cases, we proposed the current study.

Key words: Facial fracture; Initial treatment; Firearm wound; Gunshot wound.

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RESUMEN

Los profesionales de salud en Rio de Janeiro tienen que perfeccionarse en un tema que cada vez más viene ganando espacio en los hospitales públicos de Río de Janeiro: la medicina de guerra.
En el área de la cirugía bucomaxilofacial la preocupación de estos profesionales está dirigida a la devolución de la estética y función facial, teniendo en vistas que, estas heridas causan daños de grandes proporciones. En este sentido, el servicio inicial al paciente herido por arma de fuego en la cara será determinante para el éxito del tratamiento de este tipo de trauma. Este trabajo pretende, desde el relato de un caso clínico, promover discusiones con otros profesionales actuantes en el área de atención al paciente víctima de PAF (proyectil de arma de fuego). El paciente objeto de este estudio fue víctima de un asalto, siendo herido por un proyectil que penetró por la región geniana y quedó alojado en la región cervical, presentando fractura fragmentada de rama ascendiente y proceso coronoide de la mandíbula. Debido a las controversias que hay en la literatura mundial sobre las conductas en esta atención precoz , proponemos este trabajo.

Palabras clave: Fractura facial; Tratamiento inicial; Herida por arma de fuego; Proyectil de arma de fuego.

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Introduction

Rio de Janeiro in 2002 had the second highest homicide rate in Brazil, after Espírito Santo. A study by the nongovernmental organization VivaRio shows that 1 out of every 13 victims assassinated in 1995 died in shoot-outs with the police. Another somber figure is that 61% of police victims had head wounds.

In this region, gunshot wounds are inflicted with a variety of firearms. The most frequent in Rio de Janeiro are revolvers (Colt MKIV, Smith and Wesson 9mm, Colt 38) and rifles (AR-15, Fal and, AK-47). In 38 and 45-mm revolvers, the bullet is expelled from the barrel at speeds of 253m/s and 265m/s, respectively. The damage caused in the human body by the bullet is three times its diameter. In contrast, AR-15 (715 m/s) and Fal (840 m/s) rifles affect an area 30 times greater than the bullet diameter.

The treatment of gunshot wounds is divided into three phases: initial, intermediate, and reconstructive. The initial treatment is carried out by the resuscitation service to save the patient’s life.

Clearing airway obstruction by cleaning the oropharynx, intubation by tracheotomy or cricothyrotomy, control of bleeding, and the prevention of hypovolemic shock are of special importance in this phase. The use of antibiotics and antitetanic immunization is recommended in this phase of treatment because gunshot wounds are contaminated. In addition, devitalized soft tissue and sequestered bone must be removed by conservative debridement.

Neurosurgical and ophthalmologic evaluation are a prerequisite for specialized oromaxillofacial treatment.

Within this context, we report a clinical case with the aim of stimulating discussion, emphasizing the need to establish a protocol for treating patients with facial gunshot wounds.

 

Clinical case

A Caucasian patient, age 32 years, was admitted to Hospital General de Nueva Iguazú (Brasil) for the treatment of a facial wound caused by a firearm. He indicated that he had been a victim of an attempted car hijack.

The patient was evaluated first by the neurosurgery department because of the proximity of the bullet to the cervical spine. He was conscious, hemodynamically stable, and had clear airways and otherwise normal findings in the physical examination. Evaluation by the maxillofacial surgeon was requested. In the clinical examination, the diameter of the entry wound in the genial region was 1 cm at its widest and there was no exit wound (Figs. 1 and 2).

The patient had edema and pain of the left genial, mandibular, and cervical region. Radiographs of the maxillofacial region (oblique lateral mandible, posteroanterior frontal-nasal) and computed tomography were ordered.

The radiographic examination disclosed a fragmented fracture of the ascendant mandibular branch. The bullet was lodged against the cervical spine (Figs. 3, 4 and 5).

The initial regimen of medications was Keflin (antibiotic), dexamethasone, profenid, dipyrone, and gammaglobulin.

The patient was admitted to the maxillofacial surgery department for deferred surgery (reconstruction of the mandibular ramus) after the edema had remitted. (Fig. 6)

 

Discussion

Rio de Janeiro is the second-ranked Brazilian state, after Pernambuco, in deaths due to firearms (VIVARIO, 2004).

According to the investigations of VIVARIO, the death rate due to firearms has almost tripled in Brazil in the last 20 years. In 2001, the death rate per 100 thousand inhabitants of Rio was 39.7%.

Figures from this NGO indicate that more people die from gunshot wounds (29.6%) than by traffic accidents (25.1%) in Brazil. In addition, firearms kill more young men (15 to 24 years, 34%) in Brazil than all other causes combined, including disease, traffic accidents, and other external causes.

Tosta (1990), in a study of group of 400 patients attended by Hospital Municipal Souza Aguiar – RJ, found that the age group with the highest incidence was 21 to 40 years, with 233 cases (58.25%). These figures concur with others related to the patient studied in the present paper.

Cole (1994) reports that, in a series of 40 cases of facial wounds, most were due to assault (62.5%).

The location of the entry orifice in gunshot wounds is debated in the literature, but almost all the authors studied report that no exit wound is observed (KHALIL, 1980, PRIETRO, 1995).

In the case of the patient attended in Hospital Geral de Nova Iguaçu, the cause of the injury was also an attempted car hijack. The entrance wound was in the genial region and the bullet remained lodged near the cervical spine, but the spine was uninjured. The patient had a comminuted fracture of the left mandibular ramus, as described in the studies by Prietro (1995), Xavier, (2000), and Tosta (1990). The mandible is cited as the facial bone most often fractured in gunshot wounds in studies by Phillips (1977), Tosta (1990), and Demetrides (1998).

Colombini and Silva (1986) recommended the basic emergency measures applied to cases of multiple injuries as guidelines for the treatment of gunshot wounds. This was because of similarities in the aggressiveness of the trauma, which produces large volume losses that require the ligature of important arteries, like the external carotid, lingual, and internal maxillary arteries.

They describe how their department conducts the initial surgical treatment, which takes place immediately after trauma occurs, to restore the soft tissue conditions. Gunshot wounds that produce a communication between the mouth and skin receive special attention.

Their concern in the first moment is to control bleeding and ensure local surgical cleaning with the aim of ensuring an adequate blood supply as a necessary condition for effective orthopedic and neurosurgical measures. At this time, bone fragments are immobilized, the maxilla and mandible are blocked, and splints and other conventional tools are used. In cases treated by them, the reconstructive procedure was performed in the 15 to 25-day period after the acute injury. In this second intervention, antiseptic and antibiotic measures are even stricter. In the case of nerve injuries with loss of tissue, free grafts of the major auricular nerve are made.

Cardoso (2000), in a study of 27 cases of comminuted fractures due to gunshot wounds in the jaw of military policemen in São Paulo, found that most cases are treated conservatively (69% without surgery).

In a review of the records of patients who suffered gunshot wounds in three of the large emergency hospitals of the city of Rio de Janeiro, Xavier (2000) observed that mandibular fracture occurred without open wounds in most cases.

 

Conclusions

In view of the controversy reigning in the literature with regard to the treatment of victims of gunshot wounds, we recommend the evaluation of airway patency, control of bleeding, and hemodynamic stabilization of the patient the initial protocol of action in the case of facial gunshot wounds. Conservative wound debridement should be performed and analgesia, antibiotic therapy, and antitetanic prophylaxis should be given.

Soft tissue wounds must be sutured whenever possible and fractures of the facial bones have to be stabilized, preferably by rigid internal fixation or semi-rigid fixation, whenever sufficient soft tissue cover is available. The maxilla and mandible are blocked as necessary. Gaps in bones must be maintained using reconstruction plates and then filled later with bone grafts to restore facial form and function.

 

 

Correspondence:
Larissa Ramos Xavier
Rua Anita Nilo Peçanha 10A
São Francisco Niterói, Río de Janeiro, Brasil
Cep: 24360-210
Email: larissarx@hotmail.com

Recibido: 26.10.05
Aceptado: 04.02.08

 

 

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