Firearm and Explosive Wounds in Colombia

By: Roberto Joaquín Del Gordo D’Amato, MD

The country of Colombia has experienced more than 50 continuous years of armed conflict—the longest in the Western Hemisphere and one of the longest running conflicts in the world. This is a leading factor for the preponderance of firearm and explosive wounds in Colombia and one of the prevalent reasons for consultations at Colombian medical institutions.

Injuries of upper and lower extremities require an orthopaedic surgeon for appropriate management so that patients with firearm wounds can reintegrate into their daily lives with the least disruption, given the character of their wounds.

In Colombia, there is significant experience in the management of such injuries, as well as those caused by even more destructive events such as land mines. From the 1990s through 2015, 11,243 Colombian citizens sustained injuries from land mines. Those affected were largely members of state security forces, although a considerable number of civilians have also been injured.

The surgery performed on patients with wounds from armed conflict is usually different from the procedures performed on various other traumatic injuries. Wounds may contain explosive fragments, so they are always considered contaminated. These are commonly associated with massive destruction of soft tissue, bones, and other structures.

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Clinical scenarios
In wounds caused by firearms and explosive weapons, a patient’s condition can be reinforced in many clinical scenarios:

Prehospital care—According to many studies, this often proves to be the most important determinant of patient survival, taking into account initial injury and time elapsed from the moment of the incident to definitive care in a hospital center.

Prehospital care requires highly trained personnel for the initial management of polytrauma patients. Such personnel must follow the ABCDE principles of trauma as established by the American College of Surgeons:

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

With extremity injuries, prehospital care providers must be prepared to prevent shock, stop blood loss, and prevent infection. Principal objectives of prehospital care are to prevent additional damage and to identify wounds that may cause loss of life.

Emergency service—This is a continuation of care with greater technical and technological resources and the availability of multidisciplinary management teams. Priorities can be summarized in four fundamental aspects: saving the life, saving the limb, preventing infection, and minimizing residual disability.

Once the patient is stable, a physical exam from head to toe is essential, including simultaneously reevaluating vital functions, as a previously stabilized patient could experience setbacks and subsequent instability that could compromise his or her life.

With a stabilized patient, complementary exams can be performed that will help the diagnosis, allow the attending physician to obtain more complete evaluations, and allow for establishment of a treatment plan. Key points to remember are as follows:

  • An entry from a small bullet could be associated with a high degree of internal damage.
  • Missiles do not always follow straight trajectories.
  • Wounds located in the thorax could be associated with abdominal wounds or vice versa.
  • Entry wounds in the gluteal region, thighs, or perineum can be associated with intra-abdominal lesions and could include the urethra, bladder, and rectum.
  • Entry wounds in the inguinal region require consideration of the high possibility of a major lesion in the femoral vessels, as well as axillary wounds, and can be an indication of a lesion in the brachial plexus.
  • A large hematoma almost always indicates a major vascular wound.
  • Any wounds on the leg present risk for compartment syndrome.
  • In thorax wounds, cutaneous emphysema generally occurs with pneumothorax or bronchial-
    tracheal injury.
  • Multiple wounds are dangerous because of high risk that one of them may have damaged an important vital structure.
  • For patients with multiple wounds, the biggest wound is not always the most important.
  • Any patient suspected of having a pneumothorax and who has to be taken to surgery or have air evacuation must have a chest tube inserted in the affected side.

Damage control surgery or early total care—This depends on the patient’s condition and available resources. For extremely injured or unstable patients, the first option is most common. Stable patients often receive early total care. For borderline patients, once vital support measures are applied, the evolution will determine which path is most recommended.

Evaluation of sequelae and rehabilitation plans—These are based on the procedures done in the previous phase. The objectives of this care must be defined in order to utilize all available resources that may reduce the impact of disability and encourage social reintegration.

Finally, it is important to note that the medic and paramedic personnel affect the outcomes of firearm and explosive wounds, and their ability in these situations strongly depends on their experience and background.       

Roberto Joaquín Del Gordo D’Amato, MD, is an orthopaedist and traumatologist; associate professor, Universidad del Magdalena in Colombia; president, Trauma Section Sociedad Colombiana de Cirugía Ortopédica y Traumatología; and a trauma instructor with the Switzerland-based AO Foundation.

 

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