Traumatic Gun Shot Wounds From 7.62MM - Essay Example

?The current technology nowadays has brought us modern techniques particularly in the field of healthcare. These techniques employing instruments promise of easier, faster, less complications, and better outcomes relating to therapeutic management of the ill. Those times in the early periods when traditional modes of treatment were still used, it is suffice to apply simple and plain medical care, for example, to the wounded. But even, illnesses evolve. There are recently discovered organisms that are pathogenic to man while some have become opportunistic and cause disease only when man’s health and condition were compromised. It is then imperative that modalities in medicine be upgraded to combat man’s health opponents. Researches and studies in science have been very useful and relevant in conquering the battle against illnesses which commends the utilization of a wide range of treatment modalities from simple techniques to intricate equipments. Accidents or illnesses involving blood loss may lead to hemorrhagic shock which is life threatening. Although our body has its own mechanics in counteracting instability, a profound and in many cases, chronic illnesses may lead to exhaustion of the body’s system thus failing its purpose in maintaining equilibrium. Wound repair is the attempt of the tissues that are damaged to return to their normal activity and architectural and mechanical integrity after the damage. More often than not perfect restoration of fluid loss, prevention of infection, reinstating previously normal flow of blood and the lymphatic system is not achieved due to the necessity and rush to go back to and perform its function especially if the injury is severe and diffuse. Regeneration on the other hand refers to flawless restoration of the previous tissue structure without formation of a scar. While regeneration is the aim of wound healing, it only happens during embryonic growth and development and in lower forms of organisms. A fundamental concept in wound healing in humans is that all injured tissues pass with in the similar sequence of processes which are assigned into definite phases. Yet, these activities in each stage may coincide within the same time in a single wound. Every wound assumes the fundamental phase of wound repair. Acute wounds undergo the organized and well-timed process of repairing in order to attain long lasting structural and functional restoration of the tissue. Meanwhile, chronic wounds do not undergo to re-establishment of its functional integrity rather restoration is delayed in the inflammatory phase due to several causes and do not advance to the last phase (Townsend, et al., 2007). Hemostasis is defined as blood loss from a damaged blood vessel. In the setting of a severely injured or ruptured vessel the process of hemostasis can be accomplished by various methods: constriction of the vessels affected, organization of platelets to form a plug, creation of a blood clot with the virtue of blood coagulation, and eventually, production of fibrous tissue within the to permanently seal the gap in the blood vessel (Guyton & Hall, 2006). Each of the mechanics of hemostasis act in sequence but are also interconnected so as to promote multiple reinforcement to the area of impairment. Instantly after a trauma to a vessel, the injury to the wall of the blood vessel results to contraction of the wall which is in turn caused by reflexes, local spasms, and local platelet factors especially the thromboxane A2 which is a potent vasoconstrictor. In effect, the blood flow from this vessel is decreased. The contraction can last from a few several minutes to few hours in which the next step of forming a platelet plug can be initiated. If the injury to the vessel is very minute, the cut is usually blocked by a platelet plug instead of a blood clot. These little cuts in the blood vessels happen daily. The next hemostatic mechanism is the formation of the blood clot which starts to form within the first 15 to 20 seconds after the trauma, if the injury to the vessel wall was severe or within the next 1-2 minutes is the injury is small. After 3 to 6 minutes, if the opening is not huge, the entire hole or damaged area of the blood vessel is occupied by clot. Blood clot is made up of a network of fibrin fibers enmesh together in different directions to catch red blood cells, white blood cells, platelets, and plasma. This meshwork of fibrin attach to injured surfaces of vessels hence occluding any opening and preventing more loss of blood. Twenty minutes to an hour later, the clot retracts further closing the vessel. Within 20 to 60 minutes, the formed clot starts to contract and expresses most of the fluid called serum. As the clot contracts, the edges of the ruptured blood vessel are dragged together further enhancing and reinforcing to the final stage of hemostasis. Thereafter, the clot can either be replaced by fibroblasts which produce connective tissues to enhance the matrix or it can be lysed. Usually, a clot is invaded by fibroblasts several hours after the establishment of the clot. The process of producing a fibrous tissue continues until 1 to 2 weeks. However, if blood has leaked out and escaped into the tissues due to the injury, they are dissolved by enzymes called plasmin. It digests the fibrin fibers and other proteins such as fibrinogen. Plasmin is activated only after the blood clot has controlled the bleeding and after the release of its activator, the tissue plasminogen activator. Plasmin is necessary to remove unnecessary clots (Guyton & Hall, 2006). One technique that is widely used today in the field of medicine is cauterization. Cauterization is a medical word pertaining to the burning of a body part or searing tissues with a goal of removing it as in warts or ligating a blood vessel to stop bleeding. It also can be used to decrease the possibility of infecting a wound in the absence of antibiotics. It is a surgical procedure which is actually a common technique and was used long ago in the ancient times before the discovery of antibiotics. The practice is still applied today in distant parts of central Australia for wound management (Cauterization, n.d.). This process utilizes the device cautery which is usually a hot iron or electric current through an electrically charged platinum wire which is commonly known as eletrocautery or a caustic substance such as nitric acid. Cautery uses battery as source of its power to produce DC current so that the electric current does not go through the patient's body (Dictionary 3.0, n.d.).Cauterization was efficient in arresting severe hemorrhage, closing surgical wounds, and preventing infections and its complications. Actual cautery refers to the substance or instrument that cauterizes directly through application of heat while a potential cautery is the substance which burns, sears or freezes the part of the body through chemical action (Dictionary 3.0, n.d.). Cautery is mentioned and defined in the Hippocratic Corpus (Hippocratic Medicine, n.d.). It is used widely in the historical periods as counterirritant to relieve deep inflammations, as hemostatic to contract the blood vessels and control bleeding, as a bloodless knife in surgical operations, or to destroy masses and tumors (Surgical Instruments, n.d). Cauters, the instruments utilized in cauterizing blood vessels were first used in Kitab al-Tasrif by Abu al-Qasim al-Zahrawi (Hussain, 1978). He was the first to introduce the Abu al-Qasim al-Zahrawi also introduced the method of tying and ligating the arteries in replacement of cauterization. Afterwards, during the 1500s, a French surgeon named Ambroise Pare bettered the standard technique of stopping hemorrhage and used it more efficiently. He diverted from the use of cauters to utilizing forceps and stitches to stop the bleeding (Cauterization, nd.). The role of Ambroise Pare (1510-1590) in the advancement of surgery is still of extreme significance. He was the one who strengthened, modified and updated Renaissance surgical procedures. From 1536 until earlier than his demise, Pare was employed as surgeon to the army where he travelled with French armies on their journey and practicing surgical operations within the civilian community in Paris. Even though some surgeons have noticed the same observations regarding the use of boiling oil as a way of cauterizing gunshot wounds, it is Pare who used ointment of egg yolk, rose oil, and turpentine which are considered less irritating. Among Pare's significant observations was during amputation, ligation of each blood vessels was more effective rather than trying to stop the bleeding by way of mass ligation of tissues or with hot oleum. As the process was elaborated in book entitled Dix Livres de la Chirurgie avec le Magasin des Instruments Necessaires a Icelle in 1564, the free or the cut end of a vessel was doubly ligated doubly in which the ligature was let to stand and undisturbed until ligature was cast off (Townsend, et al., 2007). William T. Bovie was credited and named the father of electrosurgical instruments. However, the physical progress with these devices had been known long before Bovie. Surgeons had well been using cautery and electrical current in surgery before the early 1920s, during when Bovie invented the instrument. Nowadays, there are increasing figures of electrosurgical applications in the surgical operations and cauterization is undeniably the most frequent application of technology (Massarweh, 2006). Employment of cautery started as far as during the prehistoric periods, when the use of heated stones was utilized to achieve hemostasis. By the 6th century BC, conductive heating of damaged tissue turned to become a well known practice in the field of medicine. In the 18th century, the application of electricity in medicine co-occurred with the first scientific inventions (Wangensteen, O. & Wangensteen, 1978). Goldwyn defined various periods covering the growth and progress of the contemporary electrosurgery (Goldwyn, 1979). The first period started with the invention and utilization of static current. The next period is called galvanization the term being coined in 1786 from inadvertent discovery of electrophysiology by Luigi Galvani. The last period which ended in 1831, was filled with inventions of Faraday in England and Henry in America who were accounted by their works involving a moving magnet which could initiate a flow of electricity in a wire. It was Morton during 1881, which discovered that an alternating current with a frequency of 100 kHz can enter through the human body without inflicting pain, spasm, or burn. Similar findings were reported by d’Arsonval in 1891, which used only 10 kHz (Kelly & Ward, 1932). It is interesting to note that temperature increases proportionally with the square of the density of the current. During the19th century, Franz Nagelschmidt realized that patients suffering joint and circulatory illnesses gained from the use of electric currents. He came up with the word diathermy. His work was then pursued by Joseph Rivere, a Parisian physician, who saw a spark arching from an electrode coagulated a part of his skin. He then consequently utilized this arcing electrical current to manage a malignant ulceration located on the hand of a patient. This incident was referred to as primarily the true usage of electrical current in the area of surgery. Thereafter, utilization of currents in managing wounds of the skin, oral cavity, and urinary bladder, and for the purpose of coagulation of tumors which are vascular in nature, as well as hemorrhoids had become very ferequent (Glover, et al., 1978). During the early 1900s, Simon Pozzi coined the term fulguration a technique that consumes high voltage, low amperage, and high frequency electrical currents to cure skin carcinoma. Doyen bettered the procedure by connecting a grounding plate to the source and putting a plate beneath the patient. He determined that with this technique, the electricity infiltrated into the tissues more distant from the cautery tip a result he described as electrocoagulation (Goldwyn, 1979). It was in 1910 when William Clark used a high amperage low voltage current that generated a hotter and shorter spark. He also used a single spark instead of the traditional multiple sparks in which carbonization by dehydration or dessication of tissues was produced. He was the first American who regularly used this technique to his patients with carcinomatous lesions of skin, head, neck, cervix, and breast. Bovie created a device; a cutting loop intended for cutting, coagulation and dessication connected to a generator generating high frequency electricity. It was first used by Dr Harvey Cushing in October 1, 1926 in Boston at Peter Bent Brigham Hospital to a patient with expanding vascular myeloma of the head (Goldwyn, 1979). Generally, the technique was plain and simple: the distal end of a portion of an iron is heated over the fire and then put to the wound. This procedure tends to quickly increase the temperature of the tissue and blood thus stimulating coagulation of the blood eventually effecting to control of blood loss. Heat plays a role in hemostasis. Through application of heat, body proteins are denatured resulting in coagulation of the tissues. The basic principle of cautery functions by transmitting heat from the device and conducting it directly to the tissue. With the use of electrocautery, induction of heat comes from and alternating source of current. Coagulation of the tissues is achieved via high amplitude current which is sufficiently high so as not to produce an arc between the cautery tip and the tissue. Through this, burning the adjacent tissue external to the operative field will be avoided. This would also prevent the exit of the electric current all way through the leads of electrocardiogram, pacemakers, defibrillators or other monitoring devices. It is necessary to place a negative grounding plate underneath the patient’s back in order to keep the patient away and protect from severe skin burns. Also, direct current can be helpful in achieving hemostasis. The negative charge on the surface of the protein and cellular elements of the blood are pulled towards the positive pole where a thrombus is produced. A range of 20- to 100-mA of direct currents has effectively minimized major bleeding from raw surfaces. Several anesthetic agents are particularly not to be used with electrocautery since they can cause potential explosions. These chemicals are diethyl ether, divinyl ether, ethyl chloride, ethylene, and cyclopropane (Brunicardi, 2010). Today there are different procedures and techniques in doing cauterization. One technique is the use of a metal wire in a process called electrocautery. This procedure is used mainly to ligate bleeding blood vessels or cutting through tissues by the use of a metal probe that conducts heat by electricity to the vessels. It is also used with cancer intervention through employment of electrodessication and curettage. Unlike other methods, electrocautery is preferred over the use of caustic chemical substances because there is no potential harm on the adjacent tissues that a leak of substance may cause. One subtype of this procedure that also utilizes electric current is the electrosurgery. It functions through the production of heat within the tissue itself. Chemical cautery was initially used in getting rid of minor skin lesions as in warts and dead tissues. It is also indicated for blood hemostasis. The commonly used chemical substances are silver nitrate which is the active component of the lunar caustic. It is momentarily dipped into the water and then applied to the where the skin lesion is located. Cantharidin was derived from the extract of a blister beetle which is applied to remove and treat warts. It causes the epidermis of the skin to be necrotic and later desquamate. Also, the chemical trichloroacetic acid is used or chemical cauterization. A specific application of the cautery employed today is the nasal cauterization. This is indicated with patients suffering from recurrent epistaxis which may be due to bleeding nasal blood vessels. This procedure can prevent further nose bleeding. There are several procedures including nasal cauterization. One technique is by heating up the affected area with acid, iron rod, laser or by the use of silver nitrate until it is burned. This is painful, thus the alternative of using liquid nitrogen which usually causes less discomfort to the patient. However, liquid nitrogen is less effective compared to silver nitrate. The use of cocaine because of its analgesic and anesthetic property can be of use to relieve pain. Its ability of local vasoconstriction can also be helpful in controlling episodes of nose bleeding (Cauterization, n.d.). With hemoptysis, its frequency and impact on exchange of gases necessitates the kind of management given. Given the highest priority are patients with massive hemoptysis. Endotracheal intubation and mechanical ventilation are the prime intervention applied to patients experiencing massive bleeding. Other options considered to manage the bleeding are insertion of balloon catheter, laser phototherapy, electrocautery and surgical intervention. In this case, electrocautery, by use of an electric current is applied to the origin of bleeding. Similarly, it is also used in the controlling of bleeding due to an endobronchial tumor. Electrocautery, stent placement, laser therapy, cryotherapy, and argon plasma coagulation are techniques that have been very helpful with bronchoscopy for diagnosis as well as treatment of diseases involving the tracheobronchial tree. Cautery is also of use by surgeons in resecting polyps in the colon. Likewise, cervical carcinoma utilizes electrocautery excision which is comparable to cone biopsy. Cautery techniques can control bleeding that may be due to ulcers, vascular malformations, and tumor masses of the gastrointestinal tract. Similarly with the digestive system, sphincterotomy in the sphincter of Oddi can be performed with the aid of electrocautery. Surgical management along with cautery is also indicated with a damaged blood vessel in the brain which is usually the middle meningeal artery cut or injured by an overlying fracture of the skull (Fauci, et al., 2008). Another application of cautery is in the operation of rectal prolapsed. In the placation operation for the treatment of complete rectal prolapsed, the mucosa of the rectum was cauterized in perpendicular position beginning from just above the pectinate line to the higher limit of the segment that prolapsed by the use of a cautery probe. Four vertical cautery lines were done on each corner of the rectal prolapsed. The cauterization procedure comprises the mucosa and submucosa of the rectum such that after the procedure, a muscle is revealed. The muscle was plicated by a series of sutures which was taken through the vertical cauterization lines that would aid in controlling the prolapsed of rectal segment till the process of fibrosis happens. As a result of this study, technique involving cauterization-plication procedure is a plain and easy procedure for managing and treating complete rectal prolapsed. The results were good enough with negligible complication (El-Sibai, O. & Shafik, 2001). Another application is with the gun shot wound which can be useful in controlling blood. Management of gun shot wound deals with a through and through wound meaning a wound passed all the way through the opposite part from the entry of the bullet to its point of exit. Like most severe injuries, the foremost main concern is resuscitation. When a patient is confined secondary to a gun shot wound, any apparent external bleeding should be managed and intravenous infusion set up to the uninjured extremity. When there are no vascular or neurological damage, and X-rays are unremarkable, the wound will then be cured as an uncomplicated gun shot wound. In the Middle Ages, the consequence of wounds due to the discharge of gun powder were very severe that it was thought that a particular toxin was posited to be the source, and management with cautery or with boiling oil was used, in an attempt to counteract this. In 1560 Botallo suggested that the problem was due to foreign materials and necrotic tissue (Watts, 1960). With a through and through gun shot wound, retention of foreign elements is less likely a trouble but the more significant is the retention of necrotic tissues within the wound. Hopkinson and Marshall (1967) have noted that the injury due to a bullet is caused by the direct cutting effect, and also to the pulsating brief cavitations which is developed. Amato et al (1971) and DeMuth (1969) said that the degree of injury due to the effect of cavitations is directly proportional to the speed of the bullet. Also, the damage is associated to the mass and flexibility of the tissue involved. Hopkinson and Watts (1963) have described that added death of the tissue happens for approximately 3 days after the injury. Lawson et al (1971) noted high levels of creatinine phosphokinase and lactic dehydrogenase in the circulation until 5 days after the injury indicating that ongoing death of tissues occur during these times. Burkhalter et al (1968) have proposed that initial wound debridement should be done after a delayed primary suture. Lowry and Curtis (1950) showed that best effects are attained if suturing is done within the fourth and sixth days after debridement. The best method to keep away from infection is debridement then waiting until delayed primary suturing is carried out. Berman et al (1943) have shown that this is due to the establishment of immunity to infectious organisms. Wounds are vulnerable to Staphylococcus aureus infection within the first 24 hours. Immunity to infection is then established over the next days completing on the fourth or fifth day. Furthermore, during the Vietnam War American surgeons were given the chance of learning and applying the techniques of combat surgery. Wounds were classified into three types: gunshot wounds which results from of one or more high velocity missile, fragment wounds which results from the fragments of a high velocity device i.e. grenade, mortar round, or rocket, and blast wounds which results from the concussive effect of a device i.e. land mine or plastic. These injuries are portrayed with multiple wounds with profound tattooing by dirt and fragments. Also, associated injuries to other organ systems were common. Operative procedures are also done in the war zone. Initial surgical operation is employed to reduce contamination and infection which uses the procedure of wound debridement. At the end of these measures, hemostasis was cautiously achieved with the use of ligature and cautery. Also, application of gauze, sponges, and splint were done (Jabaley, et al., 1973). The harm imposed to the body tissues by bullets can cause injury from both direct and indirect methods. Direct method is characterized by the cutting from the original bullet and debris infiltrating through the tissues. This is the usual consequence of injury inflicted by low velocity bullets. Indirect method on the other hand is characterized by the extension and displacement of tissue due to cavitation effect of the bullet. This is usually observed with medium to high velocity bullets. There are three main components of with gunshot wounds. First is the penetration which pertains to the injured tissue damaged or disrupted by the bullet It is of note that for a bullet to penetrate the major blood vessels, it should infiltrate 7 inches deep within the abdomen. Second is cavitation which is composed of a shock like wave effect. A temporary cavity can reach up to 10 times the circumference of a medium to high velocity bullet while a permanent cavity is the opening that is created by the bullet. Injury depends on the extensibility of the flesh or tissue. Areas that are relatively elastic include muscles, blood vessels, lungs and bowels are relatively elastic hence a less permanent cavitation effect. Meanwhile, liver and brain are relatively inelastic and cavitation becomes permanent effecting to a resulting in major injury. The last constituent is fragmentation wherein projectile paths of fragments or secondary fragments i.e. bone are sent off forming their own paths through the body tissues. The size and trajectory of a gunshot wound should never be underestimated because wounds from gunshot may appear small and insignificant but internal injury may be severe. Also, a bullet from a gunshot wound is never presumed to travel (Miglietta, n.d.). There are three fundamental types of agents or methods commonly utilized in surgery to attain hemostasis. They are chemical substances that aids in blood clotting or function as local vasoconstrictors, thermal instruments that frequently makes use of lasers, electrodes, or heat for cauterization and mechanical procedures which utilize pressure and force or ligature to control and stop the hemorrhage. However, there are restrictions with the use of these hemostatic agents. One is that much of the solid substances cannot course into the injured areas that may have irregular shapes or tiny openings thus ineffective in controlling the bleeding. Next, some fluid agents such as cyanoacrylates must be in a dry setting to be efficient because if they come in contact with wet surfaces such as the blood circulation, they may trigger and cause the development of thromb (Petersen, 2004). Also, several materials and methods can effect to an immune response of the human body particularly with the use of cauterization which generates a minor burn to control the blood flow, putting another stress on the human body’s healing ability. Then, still some agents have a short duration of shelf life and must be set just prior to use, while some other hemostatic agents i.e. by-products of blood like fibrin can also be turn to adhesions and blood-borne illnesses needs very particular handling. Furthermore, many hemostats are hard to utilize in the setting of uncontrolled environments, such as platelet factor VIIa which necessitates cautious monitoring and fibrin glue which is needed to be mixed prior to its application and also must be stored below 4?C and finally, therapeutic procedures that integrate inflammation as an element of their hemostatic action demands additional caution to make sure that the local blood supply is not decreased or stopped, which could effect to extra tissue damage leading to death. Nanotechnology is quickly recognized in the modern medical technologies. One example of utilizing nanotechnology is nanohemostat which is a modern type of hemostatic agent which controls bleeding in less than 15 seconds by using (RADA) 4 pertaining to nanohemostat-1 (NHS-1), a synthetic biological agent that forms by itself at the nanoscale when placed to a wound. The consequence is the development of a nanofiber block that controls hemorrhage in any wet ionic setting within the body. NHS-1 is a nanoagent that assembles by itself into a structure and which in contrast to a therapeutic material which does not stops or promote signaling, or control processes at the cellular level. NHS-1 seems to imitate the environment during the early embryonic period when the blood flow grows to confluence and is also same to the particles that guard the new blood flow system from leaking out. Cauterization is generally applied in general and plastic surgeries, gynecology, oncology and ophthalmology. Cauteries are widely known for several medical techniques such as locating hemostasis, stopping extensive bleeders, vasectomies, removal of subungal hematoma, molding woven graft, used on tiny lesions to block bleeding in the mucous membrane of the nose, removal of warts and similar benign lesions, used in ophthalmic and minor surgery, and it is good for coagulation of small bleeding (Dictionary 3.0, n.d.). Medicine is faced with the challenge of finding an ideal hemostat. According to Spotnitz, hemostatic equipments that have the capability to minimize and stop blood loss, reduce the time of operation, and better quality of surgical issue management. These essential constituents must be taken into consideration (2008). Furthermore, he noted the top five essential functioning features of the model hemostat are safety, efficacy, usability, cost, and approvability. With safety, the agent or procedure should not create hazard to the patient, without threat of transmission of infectious disease, and no carcinogenic or immunogenic reactions of the host should transpire when utilizing the material or procedure. The material must be effective. Regarding usability, the agent must demonstrate ease of use through simple reconstitution, easy preparation, and uncomplicated application with an ample variety of application procedures intended for linear, spray, endoscopic, laparoscopic, or robotic techniques. Lastly, being the most significant, the agent should be fast acting. Meanwhile, an ideal hemostat can shorten the time interval of the surgical operation or the duration of hospital stay thus substantially lowering and cutting down the overall medical. The material should pass and be certified by the Food and Drug Administration. Drug is approved within an average of 15 years (Chambers & Rogers, 2009). When cauterization was discovered years ago, it came with good intention and with the evolution and breakthroughs in medicine, traditional procedures and methods are also upgraded to come up with better devices and techniques which is useful especially that we are dealing with human lives. References Barkun P., et al. 2004. Tissue adhesives and fibrin glues. Gastrointest Endosc, 60:327–333. Brown, S. n.d. The treatment of uncomplicated gun shot wounds. Altnagelvin Hospital, Londonderry Brunicardi, F. et al. 2010. Schwartz's Principles of Surgery 9th Edition The McGraw-Hill Companies, Inc. Cauterization. Available at < http://frankshospitalworkshop.com> Accessed [April 2, 2011] Chambers, E. & Rogers, K. 2009.Technology to Policy Case Study: RADA16 Nano-hemostatic Gel. In: Hayslett and Pater, eds. Office of Policy Analysis and Research (OPAR), Georgia Tech Research Institute. Atlanta, Georgia. Cosgriff, N. & Slakey, D. 2006. American College of Surgeons. Elsevier Inc. 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The rise of surgery: from empiric craft to scientific discipline. Minneapolis: University of Minnesota Press.21. Read More