Shrapnel Wound

Case History: 9-line MEDEVAC call from Navy SEALS on patrol in Logar Provence Afghanistan requests urgent patient pick up after a 37-year-old male Afghan soldier sustained reported shrapnel to left temporal area, and had a right blown out pupil. Evaluation of the patient on the short helicopter ride back to the Forward Surgical Team, showed that his vital signs were stable, he was A&Ox3 in mild distress, but responsive and appropriate, GCS of 15. Pt had a bandage over his head and an eye shield covering his right eye. Examination under the dressings showed a small area of penetrating trauma on the left mid skull and a fixed and dilated right pupil. Remainder of the physical assessment was non-contributory. An IV of 3 percent hypertonic saline was started in flight. Transport from point of injury to imaging and advanced surgical capabilities was 35 minutes.

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Figure 1. Left supra-temporal shrapnel wound.

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Figure 2. A/P plain film of the skull shows a large calibre bullet in the right maxillary sinus.

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Figure 3. Lateral plain film confirms location in R maxillary sinus and confirms size of bullet as a .50 caliber round.

Path of the bullet assessed to be into the left temporal area, across the posterior frontal lobe and down into the right maxillary sinus, transecting the right optic nerve. Final evaluation, four hours after the initial event, the patient was still conscious and responsive. Pt was lost to follow up as he was transported to higher levels of care, with neurosurgical capabilities.

Diagnosis: .50 caliber gunshot wound (GSW) to the head.

Discussion: Penetrating GSWs to the head are a highly lethal mechanism of injury, and even those who survive often have devastating sequelae.¹ The gold standard for evaluation of penetrating trauma, in the United States, is rapid CT scan to assess for the extent of injury.² In the deployed medical environment, routine tests such as CT are often not readily available and diagnosis and treatment can be delayed as medical evacuation (MEDEVAC) transport is arranged, as in this case. Supportive care is often the extent that far forward providers are able to render. The rapid evacuation of patients from the point of injury, accurate identification/assessment of injuries and timely movement to higher levels of care, are parts of the essential framework to saving lives on the battlefield.³

References
1. Donnarumma P, Tarantino R, Gennaro P, Mitro V, Valentini V, Maqliulo G, Delfini R. Penetrating gunshot wound to the head: transotic approach to remove the bullet and masseteric-facial nerve anastomosis for early facial reanimation. Turkish Neurosurgery. 2014;24:415-418.
2. Saito N, Hito R, Burke PA, Sakai O. Imaging of Penetrating Injuries of the Head and Neck: Current Practice at a Level I Trauma Center in the United States. The Keio Journal of Medicine. 2014;63:23-33.
3. Higgins RA. MEDEVAC: critical care transport from the battlefield. AACN Advance Critical Care. 2010;21:288-297.