Firearm injuries to head and neck

Question 1

Investigations in GSW

Answer 1

1. OPG to assess mandibular injury.
2. PA skull to screen for foreign body, fracture pattern.
3. CT scan to asses projectile path, fracture pattern tissue damage, tissue loss.
4. CT angiogram to rule out vascular injury

Question 2

Phases of management

Answer 2

Phase 1. Initial encounter
Phase 2. Definitive reconstruction
Phase 3. Aesthetic and prosthetic rehab

Question 3

Phase 1. Initial encounter

Answer 3

ABC of trauma as per ATLS 
Identify life- and limb-threatening injuries and stabilization
Imaging once patient stabilized
Emergency OT
Antibiotics
Planning for definitive reconstruction
Planning for prosthetic rehabilitation
Psychiatric and social service evaluation

Question 4

What are the management in emergency OT during initial encounter?

Answer 4

1. Mx of life- or limb-threatening injuries such as hemorrhage, intrcranial, ophthalmic injuries and other limb injuries
2. Aggressive debridement of foreign bodies and necrotic tissues, bony fragments - require serial debridement over few days as necrotic tissues became apparent after few days.
3. Establish occlusion with MMF
4. Stabilize fracture segments with ORIF at regions with adequate bone stock & soft tissue coverage
5. Stenting of facial soft tissue envelope with bone grafts or recon plates at regions with adequate soft tissue closure
6. Best possible soft tissue closure with local or regional flaps

Question 5

Phase 2. Definitive reconstruction

Answer 5

Begins after edema, microvascular damage, venous congestion, wbc and tempt has subsided
Free tissue transfer (soft and hard tissue free flap) for facial reconstruction
Nerve grafting (sural, greater auricular nerve)
Nasolacrimal drainage
Parotid duct or other salivary gland drainage

Question 6

Phase 3. Aesthetic and prosthetic rehabilitation.

Answer 6

1. Tissue debulking & contouring
2. Facial and dental prosthetis
3. Oral commisuroplasty
4. Adjunctive cosmetic procedure

Question 7

What are the concerns in GSW?

Answer 7

1 - dirty wounds
2 - penetrating injury with entry +/- exit wound
3 - damage of tissue due to high velocity projectile
4 - damage of tissue consists of tissue abrasion, burn, tattooing, ragged edges, and severe tissue loss due to cavitation
5 - significant soft and hard tissue loss (permanent cavitation & temporary cavitation)