Facial Gunshot

8132019 Facial Gunshot

httpslidepdfcomreaderfullfacial-gunshot 19

Facial gunshot wound debridement Debridement of facial soft tissue

gunshot wounds

Michael B Shvyrkov Oleg O Yanushevich 1

Moscow State Medico-Stomatologikal University Maxillo-facial Traumatology Department Moscow Russia

a r t i c l e i n f o

Article history

Paper received 29 March 2010

Accepted 10 April 2012

Keywords

Treatment of soft tissues

Gunshot wound

a b s t r a c t

Over the period 1981e

1985 the author treated 1486 patients with facial gunshot wounds sustained incombat in Afghanistan In the last quarter of 20th century more powerful and destructive weapons such

as M-16 ri1047298es AK-47 and Kalashnikov submachine guns became available and a new approach to

gunshot wound debridement is required Modern surgeons have little experience in treatment of such

wounds because of rare contact with similar pathology This article is intended to explore modern wound

debridement The management of 502 isolated soft tissue injuries is presented Existing principles

recommend the sparing of damaged tissues The authorrsquos experience was that tissue sparing lead to

a high rate of complications (476) Radical primary surgical debridement (RPSD) of wounds was then

adopted with radical excision of necrotic non-viable wound margins containing infection to the point of

active capillary bleeding and immediate primary wound closure After radical debridement wound

infection and breakdown decreased by a factor of 10 Plastic operations with local and remote soft tissue

were made on 14 7 of the wounded Only 07 patients required discharge from the army due to facial

muscle paralysis andor facial skin impregnation with particles of gunpowder from mine explosions

Gunshot face wound modern debridement

2012 European Association for Cranio-Maxillo-Facial Surgery Published by Elsevier Ltd All rights

reserved

1 Introduction

There are two types of damage with a wounding projectile

(bullet shell-splinter) direct and indirect (lateral) blows Modern

high velocity projectiles create temporary throb (pulse) cavities

inside tissue which deliver an indirect force producing serious

functional disorders and 3 morphological alteration such as hae-

morrhage thrombosis and necrosis Such damage was not

described previously (Fig 1) (Callender and Franch 1935 Rybeck

1974 Berkutov 1990 Holt and Kostohryz 1983 Rudakov 1984

Alexandrov 1985 Marshall 1986 Lukianenko 2010)

Therefore modern weapons require new approach to gunshotwound debridement There are many wound debridement concepts

described The shortest belongs to Pirogov (1941) ldquo to convert

a crushed wound into incised woundrdquo Based on my experience con-

tused crushed dead and dying wound edges must be excised to the

point of active capillary bleeding then the wound becomes an incised

wound Thewoundcan then be drained and suturedallowing wound

closure without suppuration rejection disintegration and suture

breakage Struchkov (1972) and Berkutov recommended excising

wound edges and depths with the removal of all damaged contami-

nated and blood saturated tissues After debridement wound edges

should be well perfused and resistant to bacterial invasion to ensure

rapidhealing In military maxillo-facial surgery the ldquobasicprinciples of

maxillo-facial gunshot wound debridementrdquo formulated in 1943 still

hold These principles require sparing of damaged tissues soft tissues

of wound sides which should be excised economically removing

obvious non-viable tissues only New weapons high velocity projec-

tiles and changes in wound characteristics with combined wound

quantity(woundand burn) arenot takeninto consideration(Callenderand Franch1935 Chartes and Charters1976 Berkutov1981 Holt and

Kostohryz1983 Alexandrov1985 Marshall1986) Combined wound

(wound thorn burn) quantity was increased (Fig 2)

The experience of military surgery is forgotten again and again

between wars This article aims to share my experience of facial

gunshot injury

2 Materials and methods

Working in the theatre of war in Afghanistan for 4 years I treated

1486 patients In the 2-nd World War 23 of facial injuries were soft

Corresponding author Tel thorn7 499 261 93 75 thorn8 905 537 77 28

E-mail addresses mbshvyrkovgmailcom mbshvyrkovramblerru

(MB Shvyrkov)1 Present address 7 495 Moscow 105005 Pleteshkovskii pereulok hous 8 korp 1

1047298at 17 Russia

Contents lists available at SciVerse ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

j o u r n a l h o m e p a g e w w w j c m f s c om

1010-5182$ e see front matter 2012 European Association for Cranio-Maxillo-Facial Surgery Published by Elsevier Ltd All rights reserved

doihttpdxdoiorg101016jjcms201204001

Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16



tissues wounds and 13 fractures of the facial skeleton In

Afghanistan these proportions were reversed In my 1047297rst manu-

script I would like to consider debridement of isolated gunshot

wounds of the face soft tissues of 502 (33 8) wounded In my 1047297rst

year in the central military hospital of Afghanistan I followed the

military-medical principles of cautious wound debridement

strictly It became clear to me that it was impossible to adhere to

these principles due to the use of new high velocity weaponry

Analysis of my results showed me that sparing soft tissue gunshot

wound debridement resulted in disability multiple surgical inter-

ventions and prolonged duration of treatment I performed radical

primary surgical debridement (RPSD) of gunshot wounds meaningexcision of soft tissuewound margins to the point of active capillary

bleeding This shows a normally functioning microcirculation

system in the remaining viable soft tissues which rapidly heal I

excised 3e5 mm and sometimes more of skin and mucous

membrane from wound walls Fat the most vulnerable tissue must

be excised more extensively I assessed muscle viability by the

strength of capillary bleeding and muscle jerk under the scalpel

Soft tissues have to be removed from the walls and depth of

a wound only then can successful drainage and closure be achieved

It is known that the critical concentration of microbes in

a wound is 105e106 microbes per gramme of tissue If the

concentration is increased acute purulent in1047298ammation develops

(Krizek and Robson 1975) Soft tissues excision together with

microbes decreases microbial load in a wound (Kousin et al 1981)

Microbiological examinations were performed in 235 wounds at

various times after injury from 1 h to 15 days Wound smears and

soft tissues samples from the wounds were placed into culture

medium (Shvyrkov and Demenkov 2003) Gunshot wounds were

not infected during the 1047297rst 12 h after injury Wounds were not

infected in 586e644 of the wounded within 3 days after injury

(Table 1)

Purulent in1047298ammation was found in 8 of 21 infected wounds on

the 1047297rst day only At 4e6 days after injury 707 of the wounded

were infected while suppuration happened in 561 of the wounds

Fig 1 There are three zones of tissues gunshot damages zone of primary necrosis

where cells of soft and bony tissues were perished in the wounding moment zone of

following (total) necrosis where cells metabolism stops and cells will perish the next

day zone of parabiosis where cells metabolism was braked to a great extent half of

these cells will be dead 2e3 days later line of demarcation arises here and 1047297nally zone

of healthy tissues Upper channel from old bullet down e from modern high velocity

bullet

Fig 2 Face gunshot wounds from mine explosion There are a few wound on left

forehead nose lip and cheek Several bubbles (blisters) because of burn 2 stage are

seen

Table 1

Bacterial 1047298ora availability in the face gunshot wound depending on period (term) of

wounding

Time after

injury

Patients quantity from total number in the line

Bacterial 1047298ora

is absent


is present

Altogether

patients

Quantity of

suppuration from

infected wounds

Up to 24 h 3864 4 2135 6 59 838 1

2e3 days 3458 6 2441 4 58 1562 5

4e6 days 1729 3 4170 7 58 2356 1

7e9 days 316 7 1583 3 18 746 7

10e12 days 321 4 1178 6 14 218 2

12e15 days 517 9 2382 1 28 14 3

Altogether 10042 6 13557 4 235 5623 8

MB Shvyrkov OO Yanushevich Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e8ee16 e9



At 12e15 days 821 of the wounds were infected but suppuration

occurred in only 43 At 15 days after injury bacterial 1047298ora was not

found in 426 of the wounds and suppurating infection occurred

in 415 It was assumed that microbial growth into a wound from

the skin requires a few days Skin around wounds was smeared

with a 2 iodine solution Microbial growth in the wound was not

found up to end of wound healing It is clear microbes need a few

days to grow from skin to wound

Smoliannikov (1960) measured the temperature of bullets shot

from a ri1047298e barrel It was 137e156 C As far as 600 m its temper-

ature decreased to 92e126 C Bullets travel at 600 m and in non-

penetrating unclothed facial wounds the wound is sterile

21 Primary debridement of the facial gunshot wound

A 1047298ying bullet presses air in front of itself forming a ldquofront

percussion waverdquo The bullet enters in soft tissue as a piston drives

forward the air tearing and separating the tissue A conical fountain

of ground and disintegrated tissue 1047298ies out in front of and behind

the bullet through the entrance and exit (Fig12) Thus microbes do

not remain in a wound Microbial cells on the skin surface and

tissue cells are killed by contact with bullet at high temperatures

Non-perforated and perforated soft tissues wounds which werenot in contact with a primary infected cavity (mouth nose and

accessory sinuses of nose) without bleeding and haematoma were

treated without incision of the canal These wounds were 1047297lled

with gauze saturated with proteolytic enzymes for 4e5 h with the

purpose of digesting of necrotic tissues and then 1047297lled with anti-

septic or antibiotic ointment Gauze with liniment balm Vishnevski

may be changed every 2e3 days with other medicines e once or

twice daily

In penetrating wounds there always are few non-perforated

canals created by foreign objects (splinters of bone teeth and

wounding projectiles) which are situated inside the canal These

canals must be cut and opened and the foreign object removed

Small wound infection (up to 106 microbes per gramme of tissue)

may be successfully liquidated with leucocytes but as was noted byMechnikov in 1883 (1955) a foreign body will divert part of

leucocytes toitselfIn areas of the face tissues where use of a scalpel

is contraindicated or it is impossible to incise canals without harm

for wounded (for example penetrating wound of neck lengthwise

or across of face etc) (Figs 3 and 4)

In the case enzymatic debridement is recommended Ribbon

gauze with proteoclastic enzymes in buffered solution (for diges-

tion of killed tissues) antibiotics or antiseptics must be inserted

into wound and canals in turns These medicines may be injected

around the wound For 4e5 following days it is necessary to

alternate gauze with enzymes for 3e5 h with gauze with liniment

balm Vishnevski or antiseptic liniment Usually the1047297rst granulation

tissue emerges on the 6th day and the wound may be closed with

delayed primary sutures If granulation tissues grow slowly lini-ment balm Vishnevski is poured into the wound without gauze

because it oppresses granulation tissues with its pressure After

2e3 days a canal is 1047297lled with granulation tissue and the wound is

ready for closure

Primary debridement of wound (PD) which is initially per-

formed by maxillofacial surgeon right after wounding should be

distinguished from a secondary (repeated) debridement (SD) per-

formed some time after PD was done if necessary Primary

debridement is subdivided into early PD which is performed up to

24 h after injury postponed PD e is carried out between 24 and

48 h and late PD performed 48 h or more after wounding Wound

closure was performed with continuous sutures on the tongue and

interruptedsutures in wounds in the sublingual region This may be

done through external wounds especially after splinting

Interrupted sutures were used for closure of oral cavity wound lips

ensuring continuity of the vermilion border muscles fat and skin

Wounds must be drained Local 1047298aps were utilised as necessary to

achieve primary closure (Fig 5ab Fig 6ae

c Fig 7ab Fig 8ab

Fig 3 Perforating missile wound of left cheek and mastoid process Wound entrance

is very small exit e about 4 cm diameter It should not to cut and open this canal

because crumbly tamponade with same medicines gives good result

Fig 4 Perforating missile wound from left maxilla to parotid notch (exit) with rupture

of soft palate How to cut and open this canal




Fig 9ab) Primary and secondary sutures are distinguished

depending on term wound stitching after PD Early primary suture

used in layers immediately after PD Late PD is an easier process

than early PD because 2e4 days later vital and non-vital tissue is

demarcated with a pink line on skin which can lead the surgeon toexcise non-vital tissue without damaging healing potential Post-

poned primary closure was performed 3e4 days after wound

debridement in the following cases (1) following debridement of

very contaminated wound (2) in suppurative in1047298ammation of

wound edges (3) in the absence of complete excision of necrotic

tissues These wounds were prepared with hypertonic solution

sodium chloride enzymes antiseptics antibiotics ointment lini-

ment balm Vishnevski and physical therapy (Fig 10)

Delayed primary suture was used every 6e7 days after PD in

slow cleaning wound and 1047297nally is covered with granulation

tissues Treatment of these wounds was the same

Early secondary closure after 8e16 days after PD was performed

if (1) the wound was covered with healthy granulation tissue

(2) pus debris and necrotic tissue were absent from the woundSoft unscarred tissue is mobile and easily manipulated Sometimes

only 1e2 mm of skin excision is required for good aesthetic scar

formation

Late secondaryclosurewas used rarelythat is17e31days afterPD

when (1) in1047298ammation is 1047297nished (2) granulation tissue has grown

(3) necrotic tissues separation has occurred very slowly (4) wound

borders start scarring and became tough with little mobility Soft

tissues must be mobilised with a scalpel before late closure Wound

size can be diminished with button sutures in (1) large defects of soft

tissues (2) large and heavy 1047298ap formation or (3) festering wound

edges These are either approximation (approaching) relaxation

(retention) or directive button suture used in accordance with wound

morphology Rubber stopper from antibiotics bottles lavsan thread is

used which is more comfortable than wire and buckshot In all cases

horizontal mattress sutures were used thrusting a needle into skin

2 cm away from wound border with stoppers on both sides of the

wound Approximation (approaching) button suture is used to bring

woundedgescloser gradually It is used in big wide wound or wounds

with in1047297ltrated borders when stitching is impossible (Fig 10) Afterstitching the surgeon brings wound edges together closure by hand

and the assistant knots the all threads ends together minimising the

woundbut it does remain open therefore it hasto be1047297lled with gauze

saturatedwith antisepticointmentor liniment balmVishnevski Every

2e4 days the surgeon brings wound edges closer and repositions the

suture knots Gauze with liniment balm Vishnevski may be changed

every the third day and with antiseptics or antibiotics e daily

Relaxation button sutures are applied to decrease skin tension

after wound stitching the thread ends are knotted together After

the procedure skin tension must be eliminated between button

sutures around of stitched up wound and skin tension may be

checked by 1047297nger

A directive suture is required after large 1047298ap repositioning

Intermittent wound lavage with solution antiseptic or antibioticthrough thin tubing gives good results Thirty-40 drops are infused

into wound hourly except for 6 h at night Two or three aspirating

needles are placed aroundthe wound for permanent drops infusion

of antibiotics solution or dioxidin solution

Radical primary surgical debridement of gunshot wounds is in

fact sparing debridement because dead tissue is removed and all

intact tissue is spared and retained free of purulent in1047298ammation

3 Results

In the 2-nd World War primary sutures were used in 130e150

of the wounded after sparing debridement The sutures destroyed

tissues and wound edges splayed in 500e770 patients (Zbarge

1951) Suppurative in1047298

ammation increases treatment time is

Fig 5 a e The old wound is bullet exit tangentional fracture of the mandible which was 1047297xed by device Rudko Tissuesrsquo 1047298aps were 1047297xed with two button sutures b e soft tissues

were cut off and defect was closed with bipolar scalp 1047298ap




accompanied with mental and physical trauma serious breach of

microcirculation system unsightly scarring and facial deformity

Radical PSD reduced wound infection by a factor of ten

compared to sapring debridement147 of the patients needed

local 1047298ap reconstruction during radical PSD (primarily operation) or

delayed plastic from remote area of patientrsquos body (bipolar scalp

1047298ap rope 1047298ap etc) 07 of the patients wounded were demobilised

from the army due to facial muscle paralysis ocular destruction and

impregnation of facial skin with gunpowder particles (Fig 11ab)

4 Discussion

Treatment of facial gunshot injuries especially wound debride-

ment is controversial There are two opposing approaches proposed

Some recommend economical cautious soft tissue excision with

planned secondary debridement (Alexandrov 1985 Berkutov 1975

Shaposhnikov and Rudakov 1986 Deriabin and Lytkin 1979 Owen-

Smith 1985 Rich 1968 Reis et al 1991) Others excise all necrotic

and soft tissue of dubious viability together with foreign bodies and

Fig 6 a e Wounded after mine explosion Apparatus Rudko 1047297xed the mandible fractured button sutures brought wound borders closer Neck skin was damaged too therefore it

could not be used for cheek restoration b e wounds are clean and 1047297lled with good succulent granulation c e monopolar pedicle 1047298ap from left humerus closes cheek wound d e

the same patient after 2 months




microbes to preventing in1047298ammation and toxaemia (OrsquoBrein 1973

Al-Shawi 1986 Shvyrkov et al2001) Only vital soft tissue should be

left in wound to withstand bacterial invasion Those in the1047297rst group

hold that it is impossible to distinguish dead from live tissue

However a microcirculation system supports tissue metabolism

This means that if there is active capillary bleeding after tissue

excision the tissue is alive Leaving necrotic tissue in wounds ignores

established surgical principles

However a certain relaxation in rigid attitude of military

doctorsrsquo 1047297

rst group sometimes is useful to meet Alexandrov (1985)

has written about delayed wound management ldquoRemoving

damaged tissues from the wound must be more extensive (does not

spare as require beforee MSh) those tissues which could be used

fordefect closure lose their vitality gradually and cannotbe used for

wound closurerdquo According to histopathological examination and

my experience these tissues lose their vitality at the time of injury

not 2e3 days later Histological alteration increases gradually and

necrosis becomes visible only after 2e3 days when a line of

demarcation appears The author disagrees with the position of

leading military doctors who excise tissue after necrosis has been

Fig 7 Z-plastic a e gunshot defect of lower lip b e defect liquidated with Z-plastic by Limberg

Fig 8 Wounded after perforating missile wound of the maxilla a e subtotal gunshot defect of nose b e bipolar tube 1047298ap sutured to a skin frontonasal notch c e after operation

1047297rst stage




Fig 9 a - Wounded with gunshot upper lip defect on right side due to gutter wounding b - local plastic of upper lip triangular musculocutaneous pedicle 1047298ap is cut out from lower

lip and moved to a defect of upper lip

Fig10 a e Old avulsive penetrating deep wound as a result of gutter wounding with in1047297ltrated borders b e after medical treatment wound become clean and closed with 1047297brin

ce wound borders were brought closer gradually by two approximation button sutures wound was 1047297lled with granulation tissue de thin narrow strip of skin (about 1 mm) was

cut off from wound borders (for borders refreshes) and wound closed with cooptation sutures




diagnosed The authorcontendsthat indirect lateral blow with high

velocity projectile inevitably causes tissue necrosis and considers

that cautious debridement leads to avoidable purulent in1047298amma-tion and unnecessary resource expenditure Reis et al (1991) rec-

ommended ldquo primary radical wound excision repeated every

48 h The wound is always left openrdquo This debridement cannot be

termed radical because this type of debridement requires multiple

surgical interventions

Differing from Berchenko et al (1985) and Shaposhnikov and

Rudakov 1986 the author has identi1047297ed three zones of gunshot

tissue damages a zone of primary necrosis where soft and bony

tissues are destroyed at the time of initial injury (4) a zone of

delayed necrosis where cell metabolism stops and cells perish the

day after initial injury (3) a zone of parabiosis where cells metab-

olism ceases to a great extent with cell death occurring 2e3 days

later the zone at which a line of demarcation arises (2) and 1047297nally

a zoneof healthy tissue(1) (Fig1) Dead anddyingtissues inevitably

remain in cautious debridement becoming an in1047298ammatory focus

suppuration starts These tissues became heterogeneous substance

for patientrsquos organism which tries to remove them by in1047298amma-

tion Leukocytes macrophages and tissues enzymes attack them A

bacterial 1047298ora develops lysing dead tissue and contributing to

wound cleaning Davydovski (1952) attached great importance to

microscopic1047298ora asa ldquobiological cleanerrdquo However acute purulent

in1047298ammation does not always happen Bleeding and local traumareduce tissue resistance creating favourable conditions for the

development of wound infection Kostuchonok and Karlov (1990)

stated ldquo purulent infection development is possibly only in

substrate availability for vital functions of microbes e tissues

necrosis haematoma etc Such situation happens more often in

inadequate wound debridementrdquo Acute in1047298ammation increases

tissue acidity collagen 1047297laments expand and weaken sutures start

to tear tissue wound edges diverge and the wound opens

The in1047298ammatory process is very expensive for a wounded

organism The mobilisation of leucocytes macrophages and oste-

oclasts expends much energy to demolish damaged tissue instead

of preserving this for healing The organism will reject the non-

viable tissues if they were not incised again expending energy

The appearance of a scar is also compromised by inadequatedebridement of the initial wound

The examination of the microbial growth con1047297rms the introduc-

tion of infection as a result of ingrowth of microbes from theskin not

as a result of their penetration with a bullet Most surgeons consider

all gunshot wounds to be infected This assumption is probably

correct if shreds of clothing have been incorporated in the wound

which less frequently occurs with facial wounds Shell-splinters are

hotter because explosion of the projectile occurs at higher temper-

atures In such penetrating wounds on the face ribbon gauze with

proteolytic enzymes is packed into the wound for 4e5 days the skin

is smeared with 2 iodine solution and covered with sterile gauze

Foreign object are thus encapsulated and healing occurs

Microbes take several days to grow from skin into a wound

When saliva 1047298ows into wound contamination occurs immediately

Fig 12 Conical fountain of ground and disintegrated tissues 1047298ies out in front and

behind of the bullet through entrance hole and outlet

Fig 11 a e Wounded after mine explosion with wounds burn and impregnation face and neck skin b e the same wounded there are a few granulated wounds on face and neck

and skin impregnation with burnt gunpowder both eyes were damaged




Damaged tissue cannot resist microbial invasion It is the author rsquos

practice to close intraoral wound with interrupted sutures and

isolate the wound from the oral cavity and saliva Skin grafts are

occasionally employed to allow closure of the mucosa Often

a surgeon adopts wait-and-see position and starts to use drugs

therapy on suppurating wounds or wounds covered with necrotic

tissue which is erroneous Surgical debridement of a wound must

always performed irrespective of clinical condition or the length of

time lapsed since the injury was sustained It is necessary to

remember that wound debridement ful1047297ls two functions (1)

prevention of wound infection and (2) management of established

infection Microbes and toxins are removed from the wound and

tissue regeneration is promoted by removal of suppurative and

necrotic tissues Wound debridement the 1047297rst step and conserva-

tive treatment is a second

5 Conclusion

The treatment of facial gunshot injuries is performed in accor-

dance with the following principles

1) Evaluation of the woundedrsquos general clinical condition

2) Detailed examination of the wound by means of inspection

palpation and probing probe Within the 1047297rst few hours it may

be done without of any anaesthesia because tissue loses

sensitivity to pain due to local shock

3) Radical excision of wound borders to the point of active

capillary bleeding

4) Prevention of infection

5) Flap preparation if necessary

6) Primary closure of wounds with sutures and drainage

7) Application of button sutures if necessary

8) Physiotherapy

9) Massage

10) Therapeutic physical training

Ethics statements

This work has been approved by the appropriate ethical

committees related to the military hospital of Afghanistan in

1981e1985 where it wasperformed Subjects gave informed consent

Funding source

None

Con1047298ict of interest

None

References

Alexandrov NM Surgical debridement of modern gunshot wounds In Clinicaloperative maxillo-facial surgery L 1985 431e433 1985

Al-Shawi A Experience in the treatment of missile injuries of the maxillofacialregion in Iraq Brit J Oral Surg 24 244e250 1986

Berchenko GN Shaposhnikov JG Rudakov BJ Morphological characteristics of experimental wound treatment with collagen sponge In Study reparativeprocess and method them corrections Moscow Collection of Scienti1047297c Works 1MMI 81e84 1985

Berkutov AN Progress and management of traumatic and gunshot wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection MoscowMedicina 628e662 1990

Berkutov AN Modern gunshot wound Bulletin of AMS USSR 1 40e47 1975Callender GK Franch RW Wound ballistics studies in mechanism of wound

production by ri1047298e bullets Mil Surgeon 77 177e201 1935ChartesZ AC Charters AC Wounding mechanism of very high velocity projectiles

J Trauma 16 464e470 1976Davydovski IV Gunshot wounds in men M AMS USSR 1 360e362 1952Deriabin II Lytkin MI Basic principles of gunshot wound treatment Bulletin of

AMS USSR 3 52e56 1979Holt GR Kostohryz G Gunshot injuries to the head and neck Arch Otolaringol 109

313e318 1983Kostuchonok BM Karlov VA Clinic of woundsrsquo process In Kusin MI

Kostuchonok BM (eds) Wound and wound infection Moscow Medicina264e324 1990

Kousin MI Kostuchonok BM Karlov VA Treatment of suppurating wounds InKusin MI Kostuchonok BM (eds) Wound and wound infection Moscow

Medicina 324e

484 1981Krizek T Robson M Evaluation of quantitative bacteriology in wound management

Am J Surg 130 579e584 1975Lukianenko AV Handbook of facial gunshot wound treatment Perm CLR The

Printerrsquos ldquoAsterrdquo 160 2010Marshall WG An analysis of 1047297rearm injuries to the head and face in Belfast Brit J

Oral Surg 24 233e243 1986Mechnikov II Pages of memoris vol 4 Moscow Medicina 137e161 1955OrsquoBrein DD Missile wounds Belfast 1971 Proc Roy Soc Med 66 292e294 1973Owen-Smith M Wounds caused by the weapons of war In Westby S (ed) Wound

care London W Heinemann 110e120 1985Pirogov NI General sources of military medicine vol 1 M -L Medgis 156 1941Reis ND Zinman C Besser MIB Shifrin LZ Rosen H A philosophy of limb salvage in

war use of external 1047297xator Milit Med 156 505e520 1991Rich NM Vietnam missile wounds evaluated in 750 patients Milit Med 133 9e22

1968Rybeck B Missile wounding and hemodynamic effects of energy absorption Acta

Chir Scand 450(Suppl) 1e32 1974Rudakov BJ Wounding mechanism of injuring projectiles In Shaposhnikov JG

(ed) Wound diagnostics and treatment 1984 21e

59 1984Shaposhnikov JG Rudakov BJ Gunshot wound pathogenesis and principles of their

surgical treatment Surgery 6 7e13 1986Shvyrkov MB Burenkov GI Demenkov VR Gunshot wounds of the face ENT

organs and neck In Manual for physicians vol 400 Moscow MeditsinaPublishers 15 2001

Shvyrkov MB Demenkov VR Microbial contamination of facial and neck gunshotwound Milit Med J 1 54e60 2003

Smoliannikov AB Pathological anatomy of gunshot trauma M Voenisdat p340e345 1960

Struchkov VI Modern aspects of in1047298ammation In International congress of surgeons 24-th M 1972 40e50 1972

Zbarge JP Gunshot wound of the mandible In Entin DA (ed) ) Experience of Soviet medicine in Great Patriotic war 1941e1945 ye vol 6 M Medgis163e165 1951




tissues wounds and 13 fractures of the facial skeleton In

Afghanistan these proportions were reversed In my 1047297rst manu-

script I would like to consider debridement of isolated gunshot

wounds of the face soft tissues of 502 (33 8) wounded In my 1047297rst

year in the central military hospital of Afghanistan I followed the

military-medical principles of cautious wound debridement

strictly It became clear to me that it was impossible to adhere to

these principles due to the use of new high velocity weaponry

Analysis of my results showed me that sparing soft tissue gunshot

wound debridement resulted in disability multiple surgical inter-

ventions and prolonged duration of treatment I performed radical

primary surgical debridement (RPSD) of gunshot wounds meaningexcision of soft tissuewound margins to the point of active capillary

bleeding This shows a normally functioning microcirculation

system in the remaining viable soft tissues which rapidly heal I

excised 3e5 mm and sometimes more of skin and mucous

membrane from wound walls Fat the most vulnerable tissue must

be excised more extensively I assessed muscle viability by the

strength of capillary bleeding and muscle jerk under the scalpel

Soft tissues have to be removed from the walls and depth of

a wound only then can successful drainage and closure be achieved

It is known that the critical concentration of microbes in

a wound is 105e106 microbes per gramme of tissue If the

concentration is increased acute purulent in1047298ammation develops

(Krizek and Robson 1975) Soft tissues excision together with

microbes decreases microbial load in a wound (Kousin et al 1981)

Microbiological examinations were performed in 235 wounds at

various times after injury from 1 h to 15 days Wound smears and

soft tissues samples from the wounds were placed into culture

medium (Shvyrkov and Demenkov 2003) Gunshot wounds were

not infected during the 1047297rst 12 h after injury Wounds were not

infected in 586e644 of the wounded within 3 days after injury

(Table 1)

Purulent in1047298ammation was found in 8 of 21 infected wounds on

the 1047297rst day only At 4e6 days after injury 707 of the wounded

were infected while suppuration happened in 561 of the wounds

Fig 1 There are three zones of tissues gunshot damages zone of primary necrosis

where cells of soft and bony tissues were perished in the wounding moment zone of

following (total) necrosis where cells metabolism stops and cells will perish the next

day zone of parabiosis where cells metabolism was braked to a great extent half of

these cells will be dead 2e3 days later line of demarcation arises here and 1047297nally zone

of healthy tissues Upper channel from old bullet down e from modern high velocity

bullet

Fig 2 Face gunshot wounds from mine explosion There are a few wound on left

forehead nose lip and cheek Several bubbles (blisters) because of burn 2 stage are

seen

Table 1

Bacterial 1047298ora availability in the face gunshot wound depending on period (term) of

wounding

Time after

injury

Patients quantity from total number in the line


is absent


is present

Altogether

patients

Quantity of

suppuration from

infected wounds

Up to 24 h 3864 4 2135 6 59 838 1

2e3 days 3458 6 2441 4 58 1562 5

4e6 days 1729 3 4170 7 58 2356 1

7e9 days 316 7 1583 3 18 746 7

10e12 days 321 4 1178 6 14 218 2

12e15 days 517 9 2382 1 28 14 3

Altogether 10042 6 13557 4 235 5623 8































twice daily






















ready for closure















c Fig 7ab Fig 8ab




























formation




































3 Results




















4 Discussion





































1047297rst stage




















































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e















































twice daily






















ready for closure















c Fig 7ab Fig 8ab




























formation




































3 Results




















4 Discussion





































1047297rst stage




















































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e







































formation




































3 Results




















4 Discussion





































1047297rst stage




















































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e





























4 Discussion





































1047297rst stage




















































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e











































1047297rst stage




















































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e




































































































5 Conclusion









capillary bleeding





8) Physiotherapy

9) Massage


Ethics statements




Funding source

None


None

References












Medicina 324e


















Facial Gunshot

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