World J. Surg. 22, 438–442, 1998 WOR L D Journal of SURGERY © 1998 by the Socie´te´ Internationale de Chirurgie Penetrating Chest Injuries: Unusually High Incidence of High-velocity Gunshot Wounds in Civilian Practice Ilhan Inci, M.D.,1 Cemal O¨ zc¸elik, M.D.,1 Ibrahim Tac¸yildiz, M.D.,2 O¨ zgu¨r Nizam, M.D.,1 Nesimi Eren, M.D.,1 Go¨kalp O¨ zgen, M.D.1 1Department of Thoracic and Cardiovascular Surgery, School of Medicine, Dicle University, Diyarbakir, 21280, Turkey 2Department of General Surgery, Dicle University, School of Medicine, Diyarbakir 21280, Turkey Abstract. Penetrating chest injuries are a challenge to the thoracic or an alarming rate. Herein we report our experience with penetrat- trauma surgeon. Penetrating thoracic trauma, especially that due to ing chest injuries mainly due to high-velocity gunshot wounds high-velocity gunshot wounds, is increasing at an alarming rate in our region. We report our experience with penetrating chest injuries mainly from southeastern Turkey. due to high-velocity gunshot wounds. During a period of 6 years we retrospectively reviewed the hospital records of 755 patients admitted to Materials and Methods the Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, with the diagnosis of penetrating thoracic trauma. Dicle University Medical School Research Hospital serves people The mean age was 27.48 years, and 89.8% were male. The causes of who live in 13 cities throughout the southeastern and eastern penetrating injury were stab wounds in 45.3% and gunshot wounds in 54.7%. About 30% of the wounds were due to high-velocity gunshots; and regions of Turkey. Most of the trauma patients are transferred to among the gunshot wounds 56.2% were due to high-velocity shots. The this center for their final diagnosis and treatment. The incidence most common thoracic injury was hemothorax (n 5 190) followed by of high-velocity gunshot wounds continue to rise at an alarming 5 hemopneumothorax (n 184). Isolated thoracic injuries were found in rate in this region (Fig. 1). Table 1 lists the most commonly used 53% of the patients. Nonoperative management was sufficient in 92% of the patients. Thoracotomy was performed in 8.1%. The mean duration of high-velocity firearms in our region [8]. hospitalization was 11.2 days. The mean injury severity score (ISS) was Between January 1989 and December 1994 a total of 755 20.17 6 13.87. The morbidity was 23.3% and the mortality 5.6%. Fifty patients with penetrating chest injuries were hospitalized through percent of all deaths were due to adult respiratory distress syndrome. the Department of Thoracic and Cardiovascular Surgery, Dicle Altogether 17% of patients with an ISS >25 died, whereas only 0.9% of University School of Medicine. The hospital records of these those with a score <16 died. The mortality due to firearms was 8.95%. We concluded that in civilian practice chest tube thoracostomy remains by far patients were reviewed retrospectively. Clinical data included age, the most common method of treating penetrating injury to the chest. The sex, type of injury, associated injuries, management, length of easy availability of high-velocity guns will continue to increase the hospital stay (LOS), morbidity, and mortality. An injury severity number of civilians injured by these weapons. score (ISS) [9] was calculated for each patient. The relation between the ISS and mortality was evaluated. All patients were initially seen at the emergency service by one Thoracic injuries continue to be one of the most common reasons of our thoracic surgery residents. After the initial physical exam- patients seek emergency medical care [1]. Penetrating wounds to ination and the stabilization of vital signs, chest radiographs were the chest in civilian practice result mainly from gunshot or stab obtained for all patients. Consultation with other surgical depart- wounds [2]. The experience of many civilian centers continues to ments was undertaken if required. Tube thoracostomy, if indi- support the use of chest tube thoracostomy as the primary cated, was performed in the emergency department, and the treatment of nonmediastinal chest injury with a low incidence of patient was then transferred either to our clinic or to the thoracotomy [2–6]. The mortality rate of isolated chest injuries is operating room according to his or her clinical status. in the range of 4% to 12% but increases to 13% to 15% when Prophylactic antibiotics were used in all patients. Those with another system is involved and to 30% to 35% when two or more stab wounds had a combination of penicillin and gentamicin or systems are involved [7]. cephalosporin and gentamicin. For those with gunshot wounds, Because of the easy availability of hand guns and high-velocity we used a combination of ceftriaxone, amikacin, and ornidazole. guns, especially in rural settings of southeastern Turkey, the incidence of gunshot wounds of the chest has continued to rise at Results Correspondence to: I. Inci, M.D., Department of Thoracic and Cardio- Of the 755 patients with penetrating chest injuries, 678 (89.8%) vascular Surgery, Adnan Menderes University School of Medicine, Aydin were male and 77 (10.2%) were female. The mean age was 09100, Turkey 27.48 6 12.09 years (range 3–80 years). Inci et al.: Gunshot Wounds of the Chest 439 Table 2. Thoracic injuries in 755 patients. Injury No. Hemothorax 190 Hemopneumothorax 184 Pneumothorax 144 Diaphragmatic rupture 121 Open hemopneumothorax 95 Pulmonary contusion 50 Open pneumothorax 24 Rib fracture , 216 . 213 Subcutaneous emphysema 14 Bilateral pneumothorax 9 Open bilateral hemopneumothorax 13 Pneumomediastinum 6 Thoracic wall lacerations 4 Fig. 1. Increasing incidence of high velocity gunshot wounds according to Bilateral hemopneumothorax 3 years. Open bilateral pneumothorax 3 Sternal fracture 3 Bilateral diaphragmatic rupture 2 Table 1. Commonly used high-velocity firearms in our region. Missile diameter Energy Velocity Cyclic rate patients, which was the most common treatment modality in this Brand (mm) (joule) (m/s) of firea series (Table 4). Thoracotomy (18 immediate, 43 delayed) was Iraq performed in 61 (8.1%) patients. Of 43 delayed thoracotomies, 34 Spiner-Tabuk 7.62 3 39 1993 740 30 were due to intrathoracic hematoma that resulted from inappro- AL Kadisa 7.62 3 54 4008 830 30 priate chest tube drainage. In the remaining 9 patients decortica- 3 Short-Tabuk 7.62 39 1993 670 580 tion was performed because of empyema thoracis. Eight of those Tabuk 5.56 3 45 1789 700–710 600 1 60 USA patients had laparotomy performed by the general surgery depart- M-16 A2 5.56 3 45 1789 1000 800 ment on admission. Immediate thoracotomy was performed in 18 Carbine 5.56 3 45 1789 850 906 patients. The surgical diagnosis was intercostal artery injury in China 3 eight, internal mammary artery injury in three, cardiac injury in Type 56 carbine 7.62 39 1993 710 600 two, descending aortic rupture in two, and bleeding from lung Hungary AMD 65 7.62 3 39 1993 700 600 laceration in three. In one of these three patients with lung Russia laceration, right upper lobectomy was performed because of Simonovshs 7.62 3 39 1993 735 ? severe destruction in the lobe. 3 Kalashnikov AK-47 7.62 39 1993 710 600 Delayed hemothorax developed in 9 of 54 (16.7%) patients Kalashnikov AKM 7.62 3 39 1993 715 600 Dragunov SVP 7.62 3 54 4008 830 ? between 6 and 72 hours. Chest tube drainage was sufficient for PK 7.62 3 54 4008 825 690–720 successful treatment in these patients. Spain For the whole group, the mean length of hospital stay (LOS) 3 MG-3 7.62 51 3276 820 700 was 11.2 days (range 1–134 days). The mean ISS was 20.17 6 Greece 13.87 (range 1–75): 436 had an ISS ,16, another 127 had a score MG-3 7.62 3 51 3276 820 700 between 17 and 25, and 192 had a score .25. a In rounds per meter. The morbidity rate in this series was 23.3% (176/755). The most common complications were septic problems (n 5 69), atelectasis (n 5 34), and intrathoracic hematoma (n 5 34), followed by adult The causes of penetrating injuries were stab wounds (n 5 342, respiratory distress syndrome (ARDS) (n 5 31) (Table 5). 45.3%), high-velocity gunshot wounds (n 5 232, 30.7%), low- Our mortality rate was 5.6% (42/755); 21 were due to ARDS, 14 velocity gunshot wounds (n 5 139, 18.4%), bomb injury (n 5 21, to multiple organ failure (MOF), 1 to cerebral herniation, and 3 2.8%), and shotgun wounds (n 5 21, 2.8%). to acute myocardial infarction. Two patients died intraoperatively Altogether 400 (53%) patients had isolated thoracic injuries (aortic rupture). In the remaining patient the cause of death could (Table 2). Hemothorax (n 5 190) was the most common thoracic not be determined. Among the group, 4 of 436 patients (0.9%) injury, followed by hemopneumothorax (n 5 184). Of the remain- with an ISS ,16 died; 5 of 127 patients (3.9%) with an ISS ing 355 patients (47%), 155 had one, 88 had two, 63 had three, and between 17 and 25 died; and 33 of 192 patients (17.2%) with a 49 had four associated injuries (Table 3). Neurologic sequelae score .25 died. The mortality rate according to the type of injury were present in 28 patients: paraplegia in 18, quadriplegia in 3, was as follows: stab wounds 1.46% (5/342); low-velocity gunshot and brachial plexus injury in 7. Only one patient with a brachial wounds 2.87% (4/139); high-velocity gunshot wounds 11.6% (27/ plexus injury had residual paresis, whereas the others had perma- 232); bomb injuries 19% (4 of 21); and shotgun wounds 9.5% nent sequelae.