Penetrating trauma

Penetrating trauma
Penetrating trauma
	Acute penetrating trauma from a close-range shotgun blast injury to knee. Birdshot pellets are visible in the wound, within the shattered patella. The powder wad from the shotgun shell has been extracted from the wound, and is visible at the upper right of the image.
Specialty	Trauma surgery, General surgery, emergency medicine

Last updated January 30, 2024

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.^[1]

A penetrating injury in which an object enters the body or a structure and passes all the way through an exit wound is called a perforating trauma, while the term penetrating trauma implies that the object does not perforate wholly through.^[2] In gunshot wounds, perforating trauma is associated with an entrance wound and an often larger exit wound.

Penetrating trauma can be caused by a foreign object or by fragments of a broken bone. Usually occurring in violent crime or armed combat,^[3] penetrating injuries are commonly caused by gunshots and stabbings.^[4]

Penetrating trauma can be serious because it can damage internal organs and presents a risk of shock and infection. The severity of the injury varies widely depending on the body parts involved, the characteristics of the penetrating object, and the amount of energy transmitted to the tissues.^[4] Assessment may involve X-rays or CT scans, and treatment may involve surgery, for example to repair damaged structures or to remove foreign objects. Following penetrating trauma, spinal motion restriction is associated with worse outcomes and therefore it should not be done routinely.^[5]

Mechanism

As a missile passes through tissue, it decelerates, dissipating and transferring kinetic energy to the tissues.^[1] The velocity of the projectile is a more important factor than its mass in determining how much damage is done;^[1] kinetic energy increases with the square of the velocity. In addition to injury caused directly by the object that enters the body, penetrating injuries may be associated with secondary injuries, due for example to a blast injury.^[2]

The path of a projectile can be estimated by imagining a line from the entrance wound to the exit wound, but the actual trajectory may vary due to ricochet or differences in tissue density.^[4] In a cut, the discolouration and the swelling of the skin from a blow happens because of the ruptured blood vessels and escape of blood and fluid and other injuries that interrupt the circulation.^[6]

Cavitation

Permanent

Low-velocity items, such as knives and swords, are usually propelled by a person's hand, and usually do damage only to the area that is directly contacted by the object.^[7] The space left by tissue that is destroyed by the penetrating object as it passes through forms a cavity; this is called permanent cavitation.^[8]

Temporary

High-velocity objects are usually projectiles such as bullets from high-powered rifles, such as assault rifles ^[7] or sniper rifles. Bullets classed as medium-velocity projectiles include those from handguns, shotguns,^[7] and submachine guns. In addition to causing damage to the tissues they contact, medium- and high-velocity projectiles cause a secondary cavitation injury: as the object enters the body, it creates a pressure wave which forces tissue out of the way, creating a cavity which can be much larger than the object itself; this is called "temporary cavitation".^[8] The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path.^[9]

The characteristics of the tissue injured also help determine the severity of the injury; for example, the denser the tissue, the greater the amount of energy transmitted to it.^[8] Skin, muscles, and intestines absorb energy and so are resistant to the development of temporary cavitation, while organs such as the liver, spleen, kidney, and brain, which have relatively low tensile strength, are likely to split or shatter because of temporary cavitation.^[10] Flexible elastic soft tissues, such as muscle, intestine, skin, and blood vessels, are good energy absorbers and are resistant to tissue stretch. If enough energy is transferred, the liver may disintegrate.^[9] Temporary cavitation can be especially damaging when it affects delicate tissues such as the brain, as occurs in penetrating head trauma.^{[ citation needed ]}

Location

Head

While penetrating head trauma accounts for only a small percentage of all traumatic brain injuries (TBI), it is associated with a high mortality rate, and only a third of people with penetrating head trauma survive long enough to arrive at a hospital. Injuries from firearms are the leading cause of TBI-related deaths. Penetrating head trauma can cause cerebral contusions and lacerations, intracranial hematomas, pseudoaneurysms, and arteriovenous fistulas. The prognosis for penetrating head injuries varies widely.^[11]

Penetrating facial trauma can pose a risk to the airway and breathing; airway obstruction can occur later due to swelling or bleeding.^[12] Penetrating eye trauma can cause the globe of the eye to rupture or vitreous humor to leak from it, and presents a serious threat to eyesight.^[13]

Chest

Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%.^[14] Penetrating chest trauma can injure vital organs such as the heart and lungs and can interfere with breathing and circulation. Lung injuries that can be caused by penetrating trauma include pulmonary laceration (a cut or tear) pulmonary contusion (a bruise), hemothorax (an accumulation of blood in the chest cavity outside of the lung), pneumothorax (an accumulation of air in the chest cavity) and hemopneumothorax (accumulation of both blood and air). Sucking chest wounds and tension pneumothorax may result.^{[ citation needed ]}

Penetrating trauma can also cause injuries to the heart and circulatory system. When the heart is punctured, it may bleed profusely into the chest cavity if the membrane around it (the pericardium) is significantly torn, or it may cause pericardial tamponade if the pericardium is not disrupted.^[15] In pericardial tamponade, blood escapes from the heart but is trapped within the pericardium, so pressure builds up between the pericardium and the heart, compressing the latter and interfering with its pumping.^[15] Fractures of the ribs commonly produce penetrating chest trauma when sharp bone ends pierce tissues.

Abdomen

Penetrating abdominal trauma (PAT) typically arises from stabbings, ballistic injuries (shootings), or industrial accidents.^[16] PAT can be life-threatening because abdominal organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a large volume of blood.^[2] If the pancreas is injured, it may be further injured by its own secretions, in a process called autodigestion.^[2] Injuries of the liver, common because of the size and location of the organ, present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity.^[2] The intestines, taking a large part of the lower abdomen, are also at risk of perforation.

People with penetrating abdominal trauma may have signs of hypovolemic shock (insufficient blood in the circulatory system) and peritonitis (an inflammation of the peritoneum, the membrane that lines the abdominal cavity).^[2] Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause bruits (a distinctive sound similar to heart murmurs) to be audible.^[2] Percussion of the abdomen may reveal hyperresonance (indicating air in the abdominal cavity) or dullness (indicating a buildup of blood).^[2] The abdomen may be distended or tender, signs which indicate an urgent need for surgery.^[2]

The standard management of penetrating abdominal trauma was for many years mandatory laparotomy. A greater understanding of mechanisms of injury, outcomes from surgery, improved imaging and interventional radiology has led to more conservative operative strategies being adopted.^[16]

Assessment and treatment

Assessment can be difficult because much of the damage is often internal and not visible.^[4] The patient is thoroughly examined.^[2] X-ray and CT scanning may be used to identify the type and location of potentially lethal injuries.^[2] Sometimes before an X-ray is performed on a person with penetrating trauma from a projectile, a paper clip is taped over entry and exit wounds to show their location on the film.^[2] The patient is given intravenous fluids to replace lost blood.^[2] Surgery may be required; impaled objects are secured into place so that they do not move and cause further injury, and they are removed in an operating room.^[2] If the location of the injury is not obvious, a surgical operation called an exploratory laparotomy may be required to look for internal damage to the organs in the abdomen.^[17] Foreign bodies such as bullets may be removed, but they may also be left in place if the surgery necessary to get them out would cause more damage than would leaving them.^[12] Wounds are debrided to remove tissue that cannot survive and other material that presents risk for infection.^[2]

Negative pressure wound therapy is no more effective in preventing wound infection than standard care when used on open traumatic wounds.^[18]

History

Before the 17th century, medical practitioners poured hot oil into wounds in order to cauterize damaged blood vessels, but the French surgeon Ambroise Paré challenged the use of this method in 1545.^[19] Paré was the first to propose controlling bleeding using ligature.^[19]

During the American Civil War, chloroform was used during surgery to reduce pain and allow more time for operations.^[2] Due in part to the lack of sterile technique in hospitals, infection was the leading cause of death for wounded soldiers.^[2]

In World War I, doctors began replacing patients' lost fluid with salt solutions.^[2] With World War II came the idea of blood banking, having quantities of donated blood available to replace lost fluids. The use of antibiotics also came into practice in World War II.^[2]

Related Research Articles

<span class="mw-page-title-main">Hydrostatic shock</span> Controversial theory in terminal ballistics

Hydrostatic shock is the controversial concept that a penetrating projectile can produce a pressure wave that causes "remote neural damage", "subtle damage in neural tissues" and "rapid incapacitating effects" in living targets. It has also been suggested that pressure wave effects can cause indirect bone fractures at a distance from the projectile path, although it was later demonstrated that indirect bone fractures are caused by temporary cavity effects.

Bleeding, hemorrhage, haemorrhage or blood loss is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a puncture in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination. Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties. The stopping or controlling of bleeding is called hemostasis and is an important part of both first aid and surgery.

Cardiac tamponade, also known as pericardial tamponade, is a compression of the heart due to pericardial effusion. Onset may be rapid or gradual. Symptoms typically include those of obstructive shock including shortness of breath, weakness, lightheadedness, and cough. Other symptoms may relate to the underlying cause.

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

A penetrating head injury, or open head injury, is a head injury in which the dura mater, the outer layer of the meninges, is breached. Penetrating injury can be caused by high-velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. Head injuries caused by penetrating trauma are serious medical emergencies and may cause permanent disability or death.

Stopping power is the ability of a weapon – typically a ranged weapon such as a firearm – to cause a target to be incapacitated or immobilized. Stopping power contrasts with lethality in that it pertains only to a weapon's ability to make the target cease action, regardless of whether or not death ultimately occurs. Which ammunition cartridges have the greatest stopping power is a much-debated topic.

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

Handgun effectiveness is a measure of the stopping power of a handgun: its ability to incapacitate a hostile target as quickly and efficiently as possible.

A gunshot wound (GSW) is a penetrating injury caused by a projectile from a gun. Damages may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Abdominal trauma</span> Medical condition

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.

A transmediastinal gunshot wound (TMGSW) is a penetrating injury to a person's thorax in which a bullet enters the mediastinum, possibly damaging some of the major structures in this area. Hemodynamic instability has been reported in about 50% of cases with a mortality rate ranging from 20% to 49%. Some studies have shown marked improvement in the mortality rate of patients who survived transfer to the operating room rather than being treated surgically in the ER.

References

1 2 3 Stewart MG (2005). "Principles of ballistics and penetrating trauma". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. pp. 188–94. ISBN 3-13-140331-4 . Retrieved 2008-06-12.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Blank-Reid C (September 2006). "A historical review of penetrating abdominal trauma". Crit Care Nurs Clin North Am. 18 (3): 387–401. doi:10.1016/j.ccell.2006.05.007. PMID 16962459.
↑ Enepekides DJ, Donald PJ (2005). "Frontal sinus trauma". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. p. 26. ISBN 3-13-140331-4 . Retrieved 2008-06-12.
1 2 3 4 Pollak AN, Gupton CL (2002). Emergency Care and Transportation of the Sick and Injured . Boston: Jones and Bartlett. p. 562. ISBN 0-7637-2046-1 . Retrieved 2008-06-12. Penetrating trauma.
↑ Velopulos, CG; Shihab, HM; Lottenberg, L; Feinman, M; Raja, A; Salomone, J; Haut, ER (28 December 2017). "Prehospital Spine Immobilization/Spinal Motion Restriction in Penetrating Trauma: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma (EAST)". The Journal of Trauma and Acute Care Surgery. 84 (5): 736–744. doi:10.1097/TA.0000000000001764. PMID 29283970. S2CID 23003890.
↑ W. T. COUNCILMAN (1913). Disease and Its Causes. New York: New York Henry Holt and Company London Williams and Norgate The University Press, Cambridge, U.S.A.
1 2 3 Daniel Limmer and Michael F. O'Keefe. 2005. Emergency Care 10th ed. Edward T. Dickinson, Ed. Pearson, Prentice Hall. Upper Saddle River, New Jersey. Pages 189-190.
1 2 3 DiGiacomo JC, Reilley JF (2002). "Mechanisms of Injury/Penetrating trauma". In Peitzman AB, Rhodes M, Schwab W, Yearly DM, Fabian T (eds.). The Trauma Manual. Hagerstown, MD: Lippincott Williams & Wilkins. ISBN 0-7817-2641-7.
1 2 Maiden, Nicholas (2009). "Ballistics reviews: mechanisms of bullet wound trauma". Forensic Science, Medicine, and Pathology. 5 (3): 204–9. doi:10.1007/s12024-009-9096-6. PMID 19644779.
↑ Rhee, Peter M.; Moore, Ernest E.; Joseph, Bellal; Tang, Andrew; Pandit, Viraj; Vercruysse, Gary (2016-06-01). "Gunshot wounds: A review of ballistics, bullets, weapons, and myths" (PDF). The Journal of Trauma and Acute Care Surgery . 80 (6): 853–867. doi:10.1097/TA.0000000000001037. ISSN 2163-0755. PMID 26982703. S2CID 42707849. Archived from the original (PDF) on 2020-02-09.
↑ Blissitt PA (2006). "Care of the critically ill patient with penetrating head injury". Crit Care Nurs Clin North Am. 18 (3): 321–332. doi:10.1016/j.ccell.2006.05.006. PMID 16962454.
1 2 Stewart MG (2005). "Penetrating trauma of the face". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. pp. 195–9. ISBN 3-13-140331-4 . Retrieved 2008-06-12.
↑ Jenkins JC, Braen GR (2005). Manual of Emergency Medicine. Hagerstown, MD: Lippincott Williams & Wilkins. p. 60. ISBN 0-7817-5035-0 . Retrieved 2008-06-12.
↑ Prentice D, Ahrens T (August 1994). "Pulmonary complications of trauma". Crit Care Nurs Q. 17 (2): 24–33. doi:10.1097/00002727-199408000-00004. PMID 8055358. S2CID 29662985.
1 2 Smith M, Ball V (1998). "Thoracic trauma". Cardiovascular/respiratory physiotherapy. St. Louis: Mosby. p. 220. ISBN 0-7234-2595-7 . Retrieved 2008-06-12.
1 2 Fitzgerald, J.E.F.; Larvin, Mike (2009). "Chapter 15: Management of Abdominal Trauma". In Baker, Qassim; Aldoori, Munther (eds.). Clinical Surgery: A Practical Guide. CRC Press. pp. 192–204. ISBN 9781444109627.
↑ Advanced Trauma Life Support Student Course Manual (PDF) (9th ed.). American College of Surgeons. Archived from the original (PDF) on 21 December 2018. Retrieved 17 December 2018.
↑ Iheozor-Ejiofor, Zipporah; Newton, Katy; Dumville, Jo C; Costa, Matthew L; Norman, Gill; Bruce, Julie (2018-07-03). "Negative pressure wound therapy for open traumatic wounds". Cochrane Database of Systematic Reviews. 2018 (7): CD012522. doi:10.1002/14651858.cd012522.pub2. ISSN 1465-1858. PMC 6513538 . PMID 29969521.
1 2 Blank-Reid C (September 2006). "A historical review of penetrating abdominal trauma". Crit Care Nurs Clin North Am. 18 (3): 387–401. doi:10.1016/j.ccell.2006.05.007. PMID 16962459. Prior to the 1600s, it was common practice was to pour hot oil into wounds to cauterize vessels and promote healing. This practice was questioned in 1545 by a French military surgeon named Ambroise Pare who also introduced the idea of using ligature to control hemorrhage.

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[StewartPrin05-1] 1 2 3 Stewart MG (2005). "Principles of ballistics and penetrating trauma". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. pp. 188–94. ISBN 3-13-140331-4 . Retrieved 2008-06-12.

[Blank06-2] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Blank-Reid C (September 2006). "A historical review of penetrating abdominal trauma". Crit Care Nurs Clin North Am. 18 (3): 387–401. doi:10.1016/j.ccell.2006.05.007. PMID 16962459.

[Enepekides05-3] Enepekides DJ, Donald PJ (2005). "Frontal sinus trauma". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. p. 26. ISBN 3-13-140331-4 . Retrieved 2008-06-12.

[Gupton02-4] 1 2 3 4 Pollak AN, Gupton CL (2002). Emergency Care and Transportation of the Sick and Injured . Boston: Jones and Bartlett. p. 562. ISBN 0-7637-2046-1 . Retrieved 2008-06-12. Penetrating trauma.

[5] Velopulos, CG; Shihab, HM; Lottenberg, L; Feinman, M; Raja, A; Salomone, J; Haut, ER (28 December 2017). "Prehospital Spine Immobilization/Spinal Motion Restriction in Penetrating Trauma: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma (EAST)". The Journal of Trauma and Acute Care Surgery. 84 (5): 736–744. doi:10.1097/TA.0000000000001764. PMID 29283970. S2CID 23003890.

[6] W. T. COUNCILMAN (1913). Disease and Its Causes. New York: New York Henry Holt and Company London Williams and Norgate The University Press, Cambridge, U.S.A.

[brady-7] 1 2 3 Daniel Limmer and Michael F. O'Keefe. 2005. Emergency Care 10th ed. Edward T. Dickinson, Ed. Pearson, Prentice Hall. Upper Saddle River, New Jersey. Pages 189-190.

[DiGiacomo02-8] 1 2 3 DiGiacomo JC, Reilley JF (2002). "Mechanisms of Injury/Penetrating trauma". In Peitzman AB, Rhodes M, Schwab W, Yearly DM, Fabian T (eds.). The Trauma Manual. Hagerstown, MD: Lippincott Williams & Wilkins. ISBN 0-7817-2641-7.

[maiden2009-9] 1 2 Maiden, Nicholas (2009). "Ballistics reviews: mechanisms of bullet wound trauma". Forensic Science, Medicine, and Pathology. 5 (3): 204–9. doi:10.1007/s12024-009-9096-6. PMID 19644779.

[jtacs20160601-10] Rhee, Peter M.; Moore, Ernest E.; Joseph, Bellal; Tang, Andrew; Pandit, Viraj; Vercruysse, Gary (2016-06-01). "Gunshot wounds: A review of ballistics, bullets, weapons, and myths" (PDF). The Journal of Trauma and Acute Care Surgery . 80 (6): 853–867. doi:10.1097/TA.0000000000001037. ISSN 2163-0755. PMID 26982703. S2CID 42707849. Archived from the original (PDF) on 2020-02-09.

[Blissitt06-11] Blissitt PA (2006). "Care of the critically ill patient with penetrating head injury". Crit Care Nurs Clin North Am. 18 (3): 321–332. doi:10.1016/j.ccell.2006.05.006. PMID 16962454.

[Stewart05-12] 1 2 Stewart MG (2005). "Penetrating trauma of the face". In Stewart MG (ed.). Head, Face, and Neck Trauma: Comprehensive Management. Thieme. pp. 195–9. ISBN 3-13-140331-4 . Retrieved 2008-06-12.

[Jenkins05-13] Jenkins JC, Braen GR (2005). Manual of Emergency Medicine. Hagerstown, MD: Lippincott Williams & Wilkins. p. 60. ISBN 0-7817-5035-0 . Retrieved 2008-06-12.

[Prentice94-14] Prentice D, Ahrens T (August 1994). "Pulmonary complications of trauma". Crit Care Nurs Q. 17 (2): 24–33. doi:10.1097/00002727-199408000-00004. PMID 8055358. S2CID 29662985.

[Smith98-15] 1 2 Smith M, Ball V (1998). "Thoracic trauma". Cardiovascular/respiratory physiotherapy. St. Louis: Mosby. p. 220. ISBN 0-7234-2595-7 . Retrieved 2008-06-12.

[Management_of_Abdominal_Trauma-16] 1 2 Fitzgerald, J.E.F.; Larvin, Mike (2009). "Chapter 15: Management of Abdominal Trauma". In Baker, Qassim; Aldoori, Munther (eds.). Clinical Surgery: A Practical Guide. CRC Press. pp. 192–204. ISBN 9781444109627.

[ATLS_Student_Course-17] Advanced Trauma Life Support Student Course Manual (PDF) (9th ed.). American College of Surgeons. Archived from the original (PDF) on 21 December 2018. Retrieved 17 December 2018.

[18] Iheozor-Ejiofor, Zipporah; Newton, Katy; Dumville, Jo C; Costa, Matthew L; Norman, Gill; Bruce, Julie (2018-07-03). "Negative pressure wound therapy for open traumatic wounds". Cochrane Database of Systematic Reviews. 2018 (7): CD012522. doi:10.1002/14651858.cd012522.pub2. ISSN 1465-1858. PMC 6513538 . PMID 29969521.

[Blank06quote-19] 1 2 Blank-Reid C (September 2006). "A historical review of penetrating abdominal trauma". Crit Care Nurs Clin North Am. 18 (3): 387–401. doi:10.1016/j.ccell.2006.05.007. PMID 16962459. Prior to the 1600s, it was common practice was to pour hot oil into wounds to cauterize vessels and promote healing. This practice was questioned in 1545 by a French military surgeon named Ambroise Pare who also introduced the idea of using ligature to control hemorrhage.

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