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Prepared by: Stephen Murphy, MD, FACS

Patient Presentation:
Trauma team received field notification from EMS requesting a Trauma Code-14 year old male, GSW of trunk, ground transport. The patient arrived 4 minutes later. He was awake and screaming. He states that he heard multiple gunshots but felt only 1 impact on his back side. He was injured approximately 20 minutes prior to arrival. His initial vitals: pulse 106; BP 110/64, maintaining airway, respirations at 16, O2 saturation at 99 %. He complained of pain at his right mid back. He was resuscitated according to ATLS principles. 2 large bore IVs were placed within 5 minutes. Physical exam was notable for an open wound of right midback at L2 level, oozing dark blood. He had no other open wounds. Palpable left chest crepitus was noted, but the patient had good breath sounds bilaterally. His abdomen was soft, flat and initially nontender. He was answering questions, moving his legs and had good rectal tone. GCS was 15. Portable CXR confirmed subcutaneous air of left chest wall, a metallic bullet fragment in left chest wall and another fragment in LUQ of abdomen. NO significant hemothorax was detected; a tiny pneumothorax was noted. There was a question of a sliver of free air under the left hemidiaphragm. The trauma team informed the OR of intention to intervene at 12 minutes post patient arrival. With a fluid bolus, the patient's BP was 122/60 with pulse of 90 and he continued to maintain his airway. HGB was 13. The patient was deemed stable enough to move to CT and it was felt beneficial to obtain additional information regarding abdominal solid organs, hollow viscus, major blood vessels, vertebrae, thoracic structures. The patient remained hemodynamically stable during CT scan. His systolic BP dropped to 90 while moving from CT to OR 25 minutes post arrival. CT reads were not available initially due a software malfunction. Resuscitation continued in OR; patient was intubated. Blood products were available. The patient underwent a prep including both chest and abdomen with the supposition that one bullet had penetrated the right mid-back, traversed the abdomen and diaphragm and passed through left chest. C-arm was available. The exploration started with placement of a Left chest tube-some air and 200 mls of blood were drained at initial placement with no minimal subsequent drainage. The abdomen was opened via a midline laparotomy. Approximately 600 mls of blood and enteric contents were noted and suctioned from abdominal cavity. 4 quadrants were packed and the abdomen explored. Operative findings: a 3 cm opening in the Left hemi-diaphragm was identified, debrided and primarily repaired. A 2 cm wound of the greater curve of the stomach was debrided and primarily repaired. A Left retroperitoneal hematoma was noted and left undisturbed. Meanwhile, radiology staff called the CT interpretation into the OR and confirmed the laparotomy findings, adding that there was a Grade IV injury of the Left kidney. The remaining solid organs and GI tract were not injured. The abdominal cavity was irrigated and the abdomen closed primarily. The patient remained hemodynamically stable with minimal output from the left chest tube. He was extubated in OR and transported to Pediatric ICU.

Hospital Course:
The patient remained hemodynamically stable postop and moved out of the ICU the following day. He underwent placement of a ureteral stent on Hospital Day 2 when he developed hydronephrosis and clot accumulated in his Grade IV Left renal injury. He improved after stent placement. Chest tube was removed on POD # 3. He remained in hospital for 10 days healing his wounds, recovering GI function and receiving physical therapy. He was discharged to home with his ureteral stent in place.

Follow up: The patient was doing well physically a month post hospital discharge. An appointment with PTSD counselors was arranged. The ureteral stent was removed 2 months later as an outpatient procedure. Five months following his index admission, the patient stole a motor vehicle and was tackled as he fled the scene, sustaining a concussion. He was admitted overnight for Rehabilitation Medicine consult. He was discharged to a detention center.

Teaching Points:
1. The sum of the number of bullet wounds and bullets seen on imaging should always be an even number. Bullets can pass in and out of the body, leaving an entrance and exit wound. A bullet can enter without exiting, leaving an entrance wound and a retained bullet.

2. ATLS principles apply. Life threatening tension pneumothorax is addressed in the primary survey. In a patient in NO respiratory distress with a small pneumothorax, the surgical relief may safely occur a bit later in the course of resuscitation.

3. The patient described above requires a surgical intervention. Hemodynamically unstable patients should be moved expeditiously to the OR where resuscitation and operative intervention may occur. The trauma surgeon may need to proceed with a minimum of investigation in a dire situation. In the hemodynamically stable patient, imaging can be helpful in planning the surgical procedure.

4. Though a laparoscopic approach is possible, laparotomy via midline incision remains the gold standard. The bullet trajectory was considered and CT results were not available at the start of the case. A bullet passing from the right posterior back to the left chest may traverse critical abdominal organs including Vena Cava, liver, spinal cord, duodenum, pancreas, kidneys, spleen, stomach, small bowel, colon, diaphragm, as well as critical thoracic structures. Midline laparotomy was felt to be the most prudent approach. 4 quadrants were packed with lap packs. Bleeding was controlled. The injured structures were identified and debrided. Primary repair of the diaphragm and Grade 2 gastric injury was possible but may not be. The trauma surgeon must be ready for a damage control procedure with temporary abdominal closure and subsequent planned return to OR.

5. Violent intentional injury is the most poorly addressed public health problem in the U.S. according to American College of Surgeons-Committee on Trauma. Teen males of color are disproportionately represented. Males account for 85 % of firearm related mortality. Firearm injury constitutes the second leading cause of death in the pediatric population, trailing only motor vehicle collisions. The presence of a firearm in the household is associated with an increased risk of injury and death. Recidivism rates are as high as 40 %. A 20 % 5 year mortality is a sobering statistic. Increased exposure to Adverse Childhood Events (ACE) increases the risk for perpetration of violence. Social determinants of health factor heavily into the risk for firearm injury.

6. Hospital Performance Improvement: The Trauma Tertiary Performance Improvement review addressed the issue of lack of real time access to critical imaging in this scenario. This sentinel event could potentially have negatively impacted patient outcome. Through the Trauma PI Program, Trauma system concerns were moved forward to the Hospital PI forum. The Medical Imaging Department implemented solutions on an educational and institutional level to ensure the communication of crucial radiology findings to the clinician in a time critical situation.

Resources/References:

1. Westreich M. The Odd or Even Bullet. Injury 1986; 17: 45-6

2. American College of Surgeons. Advanced Trauma Life Support Course Manual, 10th ed. Chicago: American College of Surgeons, 2018

3. Yanchar NL, Woo K, Brennan M, et al. Chest X-Ray as a screening tool for blunt thoracic trauma in children. J Trauma Acute Care Surgery. 2013; 75(4); 613-9

4. Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis: Am J Surgery. 2015; 209(5): 864-8

5. Petty JK, Henry MCW, Nance M, Ford H, APSA Board of Governors. Firearm Injuries and Children: Position Statement of the American Pediatric Surgical Association. Pediatrics. 2019; 144(1) e20183058

6. Fowler K, Dahlberg L, Haileyesus T, et al. Childhood Firearm Injuries in the United States. Pediatrics. 2017, e20163486

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