Initial/Ongoing Management
QM 2014
 Before we begin;
 EBR on TBI secondary to ballistic wounds
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appear contradictory
Following is based on
1. US, UK, ADF conflict stats
2. Civilian critique of research methods by
Smith et al.
3. Hellenic Military Academy – ‘unique’
U.S. Civilian Forensic Experts, Texas, USA
QM 2014
 Basic background to Ballistics
 Hi/Low Velocity Rounds
 Basic Wound Types Upon
Presentation (What to look for)
 Secondary complications/
‘Sequelae’
 Initial /Ongoing Management
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 KISS
 No two situations are the same.
 However, if the victim is able to give:
 1. Distance – approximate (from assailant)
 2. Round Type – Pistol or longarm (rifle)
 Management approach can be pre-empted
 But first the basic differences in weapon types …
QM 2014
 Muzzle velocity is the initial speed of the round as
it exits the barrel – particular relevance to close
proximity pistol round wounds
 Pistol rounds (9mm) have relatively high muzzle
velocity, 300 – 350m/s, with exceptional
penetrating power at short distances for both soft
and hard nose rounds (round = bullet)
 Rapid decrease in velocity over short distance
(20 - 60 metres)
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picsbox.biz/key/9mm bullet drop chart
globalsecurity/.org
 Any form of deflection, obstacle has significant
effect on penetrating power eg. thin, outer panel of
car door (mushrooming, tumbling).
 Centrefire longarms have higher muzzle velocity,
900 – 950 m/s and higher speeds over longer
distances – due to design, rifling – as opposed to
pistol rounds.
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guns.com
 High Velocity Rounds
Bone - Shattering
- Non-Reparable
- Complex, distal effects
 High Velocity Rounds
Flesh – Depends on round type - Tumbling
- Penetrating
Tumbling – Extensive, complex
Penetrating – Possibility of very little
damage as opposed to low velocity rounds
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 Low Velocity Rounds
 Bone - Lower possibility of shattering
- Significantly reduced possibility of
distal effects, TBI
 Flesh - Depends on round type (hollow point)
- Likelihood of extensive damage, used
deliberately in CQB, by SF/SO
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 Not all research papers recognise the significant
difference in round velocity to distance in handgun
bullet wounds
 ‘(In ballistic wounds) the essential condition is the
distance to target’ - Alexandropoulou &
Panagiotopoulos, 2012
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 In summary, large calibre longarms and most
pistols (9mm +) at close range significantly
increase likelihood of TBI from pressure waves
 Pistols at ‘most’ distances cause significant damage
to flesh
 Victim may be ‘lucky’ with high velocity flesh
wound from a longarm*
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 In addition to the penetration medium (bone, flesh or
combination) three other factors affect wound type
 Permanent cavity destroyed upon entry – missile
morphology and velocity
 Fragmentation – missile or bone – not all wounds
 AND ….
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 Temporary cavity (5 – 12cm radius) – extension of
permanent cavity by kinetic energy transported in
tissues by missile
 – Serious implications for surgery within the first 3
hour window in assessing tissue to be excised.
 Vasospasm – approx. 3 hrs. from hi-vel. wound –
colour, bleeding, contractility and consistency
parameters for surgery assessment.
 3 hrs. vasospasm/constriction followed by
hyperaemia*
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 TBI from a distal injury not to be confused with
injuries from the temporary cavity.
‘Injuries from the temporary cavity are more
common in closer proximity to less elastic (brain, liver
spleen), fluid filled and dense tissue. Elastic tissue
(skeletal muscle) and lower density (lung) are less
affected.’
Snow and Bozeman, 2010
QM 2014
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Pressure Wave induced TBI
‘ … instantaneous perturbation of dentate interneuronal networks by a transient pressure wavedelivered to the neocortex (2)’
Results from combined human (DVBIC) USA),
animal and simulated compound research
Neuron loss in the hippocampus – Hilus of the
dentate gyrus due to pressure wave
Cells are large and not tightly packed
QM 2014
Wikipedia Commons
Wikipedia Commons
 TBI - Damage to the hippocampus, then damage to the
hypothalamus if pressure wave strong enough
 BBB - appears to open periodically within first 24
hours of TBI – allowing passage of proteins and
substances otherwise excluded from the brain .
Alterations to brain osmolarity and oedema formation
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 Over expression of Aquaporin channels – permit
movement of water into lateral ventricles > exacerbate
cerebral oedema
 Glutamate (excitatory neurotransmitter) causes influx
of Sodium and calcium > hi intra cellular
concentrations after TBI.
QM 2014
 Excess Calcium initially buffered by sarcoplasmic reticulum,
eventually saturated, excess taken up by mitochondria
acting as ‘calcium sink’ under stress situations
 With other stimuli, mitochondrial permeability transition
pore forms > depolarization, swell with calcium intake, leak
due to intra-organelle oedema and ATP production becomes
deficient. In a highly metabolically active cell > energy
failure. Cytochrome C is also released which promotes
apoptosis.
 High IC Ca+ attacks cytoskeleton, cytosolic proteins and
DNA structures
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 And;
 Head impact after insult – compounding factor
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 A – Airway – C Spine protection/Haemorrhage control
 B – Breathing
 C – Circulation/Compressions
 D – Defib./Disability
Observe for: Ecchymosis (do not confuse w/bruising)
Paralysis of face muscles
Declination of eyes to one side
CSF liquid from ear, nose or wound
One short, lucid interval followed by
reduced LOC, headache, nausea and vomiting
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• Fluids
• Oxygen
• BGLs - Insulin
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 Ideal state – Eu to moderate hypervolaemia
 Isotonic and hypertonic fluids – essential early
intervention to maintain cerebral perfusion. To be
managed with delayed hyperaemia that can lead to
cerebral oedema and inc. ICP
 NS not Lactated Ringers/Hartmann's
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 Fluids do not replace O2 carrying capacity. At some
point blood will have to be given in severe cases.
 ICP to be maintained at < 20mmHg and CPP at
>60mmHg (hospital based monitoring)
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 O2 – caution excess
 Up to 50% pre-hospital admissions, inadvertent
hyperventilation leads to pCO2 < 33mmHg > incr.
mortality in patients with TBI.
 Hypocapnea - Implications for vasoconstriction , reduced
cerebral blood flow and regional ischemia.
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 O2 – Caution excess/under use
 Insufficient O2 - Common problems associated with
TBI are changing LOCs and transient periods of
hypoxia. Hypoxic periods > bradycardia in TBI patients
and exacerbate secondary brain injury
QM 2014
 IIT background Lantus/Levemir, medium short acting
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if time, circumstances permit
Glucose
Constant BGL monitoring
Conservative control, both hyper and hypoglycaemia
can aggravate primary brain injury
Insulin – assess short, medium, long acting
Serious implications for brain energy
‘Meta-analysis’ – does not support IIT
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 Hypothermia
 Randomized trials at 37 & 30 Degrees Celsius
 Reduce glutamate release and free radical production
after TBI. Essential to maintain therapeutic levels for
CNS signalling. Excess glutamate responsible for
neurological dysfunction associated with TBI.
 Glutamate levels increase by over 250% in the dentate
gyrus alone in mild brain injury
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 Magnesium Salts – with mannitol to improve
brain bio-availability - Mg down regulates
aquaporin 4 reducing cellular oedema*
 MgSO4 induces smooth muscle relaxation,
principally in the airway
 Clinical trials stating that Mg was of no benefit –
pts required intracranial brain surgery within 8
hrs or had the GCS of a rocking chair
 Cyclosporine A – inhibit opening of the
mitochondrial permeability transition pore.
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 DVT/PE Prophylaxis
 Compression stockings
 Hold LMW heparin/low dose unfractionated heparin until
48 – 72 hours after admission – possible risk for expansion
of intracranial haemorrhage
 Stress Ulcer Prophylaxis (Severe TBI)
 PPI infusion – most effective (Pantoprazole)
 H2 blockers – block histamine, reduce enteric acid
(location)
 Sucralfate – duodenal ulcers – specific to stress ulcer proph.
 Early enteral feeding
QM 2014
Avoid:
 Calcium channel blockers
Reduce systemic blood pressure and CPP
 Corticosteroids
Bleeding, hyperglycaemia, increase in cerebral
metabolic rate and fluid retention
QM 2014
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Principally hospital based
 Prevent sequelae – ischemia, haematoma, vasospasm
 Pulse Oximetry
 Intraparenchymal Brain Catheters increasing in use
due to ease, versatility and ‘short learning curve’ (ICU)
 ICP and PtiO2/PbrO2/PBTO2 determine treatment
QM 2014
 To determine benefits of MgCl2 over MgSO4 –
possibility of reduced toxicity with MgCl2
 Possible benefits of Substance P inhibitors in TBI
patients
 Oestrogen and Progesterone in TBI management
 Mg in combination with
Tirilazad – nonglucocorticoid neuroprotectant to
reduce vasospasm
B2 – Antioxidant, NS function
Dexanabinol – anticonvulsant, neuroprotectant
QM 2014
 Tape paper bags to the hands of GSW victims until
police swabs completed
 Place any cut/discarded clothing in paper, not
plastic bags due to condensation and damage to
potential evidence.
QM 2014
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Alexandropoulou, C., & Panagiotopoulos, E. (2010). Wound Ballistics: Analysis of Blunt
and Penetrating Trauma Mechanisms. Health Science Journal, 4(4), 225-236.
Courtney, A., & Courtney, M. (2007). Links between traumatic brain injury and ballistic
pressure waves originating in the thoracic cavity and extremities. Brain Injury, 21(7), 657662
Davis, D., Fakhry, S., Wang, H., Bulger, E., Domeier, R., Trask, A., & ... Robinson, L.
(2007). Paramedic rapid sequence intubation for severe traumatic brain injury:
perspectives from an expert panel. Prehospital Emergency Care, 11(1), 1-8.
Dr. Vincent J. M. Di Maio, Chief Medical Examiner and Director of the Regional Crime
Laboratory, County of Bexar, San Antonio, Texas (from his Gunshot Wounds, CRC Press,
Boca Raton, FL, 1985).
Sen, A, & Gulati, P. (2010). Use of Magnesium in Traumatic Brain Injury.
Neurotherapeutics: The Journal of the American Society for Experimental
NeuroTherapeutics.
Snow, A., & Bozeman, J. (2010). Role implications for nurses caring for gunshot wound
victims. Critical Care Nursing Quarterly, 33(3), 259-264
Wallace, D. (2009). Improvised explosive devices and traumatic brain injury: the military
experience in Iraq and Afghanistan. Australasian Psychiatry, 17(3), 218-224.
QM 2014
 DVT Prophylaxis
 http://www.sjtrem.com/content/20/1/12
 IPBC;
 http://www.slideshare.net/pgpapanikolaou/083009pa
panikolaoupanagiotis439744
 The Dentate Gyrus;
 http://www.jle.com/en/revues/bio_rech/mrh/edocs/00/04/11/9B/article.phtml
QM 2014