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Thomas Scalea, professor of surgery at the University of Maryland Medical Center's R Adams Cowley Shock Trauma Center, who has treated thousands of patients with gunshot wounds over his three-decade career. The most important factors, in terms of a person's survival odds, are the location of the injury, the amount of blood lost and how quickly the victim is transported to the hospital, said Scalea, who is not involved in the care of the Aurora shooting victims. Being shot in the trunk or torso is more life-threatening than being shot in an extremity, Scalea said.

And within major organs such as the heart or liver, some injuries are more serious than others because they cause more bleeding, Scalea said. For example, being shot in the left side of the heart generally causes more bleeding than being shot on right side of the heart, because the right side has lower blood pressure, Scalea said. An injury to more than one of the heart's four chambers causes more bleeding than an injury to only one chamber, and a wound that goes through the septum — which separates the heart's left and right sides — is worse than an injury that does not go through the septum, Scalea said.

With gunshot wounds that involve the liver, an injury to the organ's center causes more bleeding than an injury to its periphery, and a wound on the right side is worse than the left, Scalea said.

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The main concern with gunshot wounds that involve the intestine or stomach is not bleeding, but infection s that result from spillage of the contents of those organs, Scalea said. Soldiers in Afghanistan will start receiving the armour at the end of this month after the Australian manufacturer lifted production last week, following news of the Aussie casualties. Lance Corporal Jason Marks was killed in a firefight with Taliban forces. Four others were wounded but survived. The armour comes in two camouflage covers - one for desert warfare, the other for jungle operations.

There was a moderate amount of fluid in the lower abdomen and right upper quadrant, which was partly loculated and could represent infected fluid. A right internal jugular triple lumen catheter was placed and normal saline boluses were begun. The patient was taken to the operating room. Coffee ground-appearing emesis was now present in the suction canister of the NGT. Urine output was scant. Intraoperatively, ischemic bowel was noted. The small bowel was resected from an area distal to the ligament of Treitz to the distal ileum, and the remaining portion was anastomosed.

A portion of the large bowel proximal to the splenic flexure was resected with the proximal portion brought to the skin to form a colostomy. The patient received four additional units of fresh-frozen plasma postoperatively. The patient lost vital signs 4 hours after operation. An attempt was made at resuscitation, as per advanced cardiac life support guidelines; however, the patient expired. An autopsy report was obtained. The cause of death was determined to be intestinal necrosis and peritonitis due to multiple gunshot wounds of the buttocks with perforation of the intestine.

There were four penetrating gunshot wounds of the buttocks. One of these caused perforation of the peritoneal cavity and intestine, which lead to marked peritonitis and resultant intestinal necrosis.

The Sydney Morning Herald

The collective wound tracks of the penetrating GSWs passed throughout the soft tissue of the buttocks in a back-to-front direction. Only one wound track entered the peritoneal cavity. This track ended in the lumen of the intestine. It was associated with marked yellow-red fibrinous exudates, which surrounded the right liver, spleen, mesothelial surfaces of the peritoneal cavity, and patches of the remaining serosal surfaces of the small and large intestines.

Three bullets were recovered postmortem. A grey-discolored, small-caliber bullet was recovered from the intraperitoneal track.


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A small-caliber, yellow, metal-jacketed bullet was recovered from the left pelvic bone at the sacroiliac joint. A similar-appearing bullet was recovered from the anteromedial right thigh. The remaining intestines had alternating sections of smooth, tan, edematous mucosa with areas of dusky red discoloration. The colon wall was markedly edematous and without perforating defects. There were moderate adhesions between the bowel loops. Lung microscopy revealed moderate acute bronchioloalveolar pneumonia. The liver was found to have centrilobular ischemia.

The serosal surface of the small and large intestines showed mixed chronic and acute inflammatory infiltration. The muscularis layers of the small intestine had hemorrhagic necrosis with focal preservation of the overlying mucosal epithelium.

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Embolism by definition refers to the migration of solid, liquid, or gaseous substance from its point of origin to a distant site. The solid particle can be missile, thrombus, or even a medical device. The liquid can be amniotic fluid. The gaseous substance could be a nitrogen or atmospheric air bubble [ 3 , 4 ].

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Emboli are propelled through a vessel by the flow of blood, air pressure, or active or passive body movements [ 5 ]. The first bullet embolism was reported by Thomas Davis in This case was subsequently cited later, in , by Bland-Sutton [ 6 ]. Most of the reports published in English literature are in the form of isolated case reports. One of the earliest and largest report series was by Mattox et al. It comprised 28 cases spanning 12 years and provided one of the most significant contributions to understand this rare phenomenon [ 7 , 8 ].

In case of penetrating trauma, the bullet loses its kinetic energy during its travel along its trajectory and remains within the domains of the body cavity. Bullet embolism occurs when a bullet penetrates the body, its movement is stalled, and then it is carried away from its initial site of lodgement to a distant location. Bullet emboli, in themselves, are rare phenomena.

Most reports are regarding military conflicts or vascular emboli. A study by Rich et al.

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This study shows, in a battlefield environment, the incidence of bullet embolism was exceedingly low. Only 3 cases described a whole bullet vessel embolus. The other cases described mostly fragments from explosive devices. A year retrospective review by Sandler et al. In , Adegboyega et al. The authors concluded that embolization occurred twice more frequently in the arterial system compared to the venous system. The left leg was twice more likely than the right to be involved, which can be explained by the asymmetry of the aortic bifurcation.

Twenty percent of these patients with arterial bullet embolism were asymptomatic, while In odd events, missile emboli have even been reported to enter arterial circulation through the heart [ 12 — 17 ].

Isolated reports of distal arterial embolization from peripheral arteries have also been published [ 18 , 19 ]. The embolism is anterograde in the majority of cases. Rare cases of retrograde venovenous [ 20 — 22 ] and paradoxical [ 23 ] emboli have also been reported. The embolism in this case might have occurred shortly after the initial injury or in the perioperative resuscitative phase. Other reports have shown that embolization has been delayed for days, weeks, or longer [ 8 , 24 — 26 ]. Cardiac bullet emboli can cause cardiac irritability, delayed embolism [ 22 , 28 , 29 ], and recurrent pericardial effusions and may even interfere with valvular functioning [ 7 ].

Clinical manifestations are often attributed to the site of penetration of the vascular system, the injury to other viscera, or the site of the embolization. These can all cause delay in diagnosis, which can result in adverse outcome or even death. The signs and symptoms may not correspond with those expected from the presumed course of the bullet. When a bullet is found in an unexpected location, deviant from the conventional trajectory, embolism should be suspected.

Pain, claudication, paresthesia, gangrene, pleural or pericardial effusion, endocarditis, sepsis, cardiac arrhythmias, pseudoaneurysm, or even neuroses and psychoses are some of the delayed presentations [ 7 ]. Although the final endpoint of an embolized bullet is unpredictable, some consistent patterns have become elucidated as more cases are reported.

A peripheral venous embolus generally terminates in the right side of the heart or in the pulmonary artery. A bullet that enters the right side of the heart will commonly embolize to the pulmonary artery, while pellets or small missiles starting from the left side of the heart are likely to embolize into the middle cerebral arteries. The flow pattern into the innominate artery, which is the first and largest branch of the aortic arch, is the causative factor.

Bullets from the thoracic or abdominal aorta usually lodge into the arterial tree of the lower extremity. Left leg involvement is more likely due to the axis of the left common iliac artery forming a narrower angle 30 degrees from the aorta than from the right side 45 degrees [ 19 ]. The guns and ammunition used in a trauma are also important to identify, because bullet emboli are more common with smaller, blunt-nosed, short-length, or low-velocity bullets [ 1 ].