Management challenges in a short-range low-velocity gunshot injury
A 25-year-old male patient was brought to the emergency at 11 am with a history of being shot with 0.32 bore 9 mm pistol from a distance of about 10-15 m. An initial attempt to arrest bleeding was made by applying pressure dressing and intravenous fluid (iv) resuscitation at a primary care center and referred to our hospital situated 60 km from the site of accident. Day 1: At the time of presentation, the Glasgow coma score (GCS) was 6 (E1V1M4), tachycardia (100 beats/min), tachypnea (24/min), and hypotension (90/60 mm of Hg). The patient was in a state of confusion with profuse bleeding from oral cavity, left cheek and nasopharynx with evidence of difficulty in maintaining airway. The left eye was normal but the right eye was blind with limbus perforation, and uveal prolapse. He had sustained penetrating injuries to the head, neck, upper and lower limbs. The bullet entry wounds [] were found in the right cheek, right post auricular, right neck, right upper limb, and left thigh region. The only exit wound was seen in the left cheek [].\nOral and nasal route of intubation was not possible due to continuous bleeding into the mouth and nasopharynx; edema obscured the anatomy of neck and therefore, a percutaneous needle tracheostomy was performed and airway secured. The blood investigation revealed hemoglobin of 8 g/dl and blood group AB positive. Two peripheral cannula were secured using 18 gauze needles and fluid infusions started initially with crystalloids 2 RL (ringers lactate) and 2 DNS (dextrose 5%+ normal saline 0.9%), Expan 6% (hydroxyethyl starch, plasma expander) and one fresh cross matched whole blood. The patient was catheterized using Foley's catheter to monitor urine output. Drugs that were started intravenously (iv) included Mannitol 100 ml/8 hourly, inj.Melpred (Methyl prednisolone) – 500 mg/100 ml normal saline 12 hourly, Epsolin (phenytoin sodium) 100 mg/8 hourly, Inj.Aciloc 50 mg (Ranitidine) 8 hourly. The antibiotics included Inj.Lactaguard – 1 g (Cefaperazone – 0.5 g+Salbactam – 0.5 g) iv 12 hourly, Inj.Linox (Linezolid) 200 mg/100 ml iv 12 hourly, Inj.Metrox – 100 ml (metronidazole 500 mg) iv 8 hourly.\nOnce the patient was stabilized, conventional lateral and antero-posterior skull, upper and lower limb radiographs [Figures –] and CT scan [Figures –] were obtained. Under general anesthesia thorough wound debridement was performed using isotonic saline and diluted povidine iodine solution. Intraoral debridement included broken teeth and alveolar bone in the left maxilla and mandible. The bullets were retrieved from left posterior maxilla, right infratemporal fossa, medial to right ramus region, right forearm and left thigh region with the help of C-arm guide [Figures and ]. Multiple small metal pieces in the right posterior orbital cavity, temporal lobe of brain, and right neck region were left untouched. Upper and lower eyelets were placed and intraoral and extraoral lacerations closed. The cheek wound was undermined and closed primarily. A nasogastric tube was placed and the patient was put on maxilla-mandibular fixation (MMF).\nDay 3: The patient went through a hemodynamic instability as he developed fever of 102–104°C and tested positive for malaria parasite Plasmodium Vivax. This was successfully managed with antimalarial drug (chloroquine 25 mg/kg/day) for 3 days. The methyl prednisolone and linezolid were discontinued at the end of 3 days.\nDay 8: The tracheostomy tube was replaced as the mucous secretions caused airway obstruction and discomfort to the patient. The patient complained of hearing impairment from the right ear and examination revealed stenosis of the auditory canal which was corrected surgically by recanalization by the ENT surgeon. At the same time since the right eye vision was lost, a complete evisceration was carried out by an ophthalmologist. Day 14: The tracheostomy tube was removed and discharged with MMF and oral antibiotics for 1 week.\n9 weeks: The patient was kept under observation for a total of 9 weeks for a complete recovery from the physical and psychological shock. At the second stage left iliac crest bone graft was used to reconstruct the segmental mandibular defect and stabilized with reconstruction plate []. 9 weeks 3 days: During his stay eye prosthesis was made. He had quite reasonably restored facial contour [] with satisfactory mouth opening and occlusion []. The patient refused to undergo any more surgical procedures and therefore the left marginal mandibular weakness and dental rehabilitation remained untreated.