Treatment protocol for high velocity/high energy gunshot injuries to the face

Abstract

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Keywords: face; gunshot injuries; high energy; high velocity; treatment protocol.

Figure 1

(A) Photograph of a soldier with severe shrapnel injury from an antitank missile. (B) 3-D reconstruction of the computed tomography scan for injury evaluation and 3-D surgical planning. (C) Photograph of the reconstruction performed in the primary surgical care; notice preservation of bilateral mental nerves and reconstruction using both monocortical semirigid fixation for fracture simplification and bicortical rigid fixation with load-bearing reconstruction plate. (D) Panoramic postoperative X-ray. (E) Photograph of the patient at the end of the primary surgery; notice that no skin graft or free flap was needed for primary closure. (F) Panoramic X-ray at the end of the iliac crest bone graft second surgery. (G) Functional rehabilitation using dental implants. (H) Photograph of the final result 1 year after injury.

Figure 2

Maxillofacial ballistic injuries flowchart of treatment protocol. CT, computed tomography; FAST, focused assessment with sonography for trauma; MMF, maxillo-mandibular fixation; PEG, percutaneous endoscopic gastrostomy; ECA, external carotid artery.