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Mon, 11 Feb 2002 12:31:16 -0500

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Avi,

Sounds like a monumental challenge in reconstruction.  Especially in a young
adult, one would assume that the best approach would be methodical and
multidisciplinary.  What are your resources in colorectal and gyn?  I don't
see the need or benefit of rushing, but then, I'm no surgeon.  I'll follow
the responses with interest.

There is of course no way to regard this case as anything but purely and
pathetically preventable.  Perhaps your patient would consent to Arafat
attending each of her surgeries.  Surely some similarly brutalized
Palestinian would do the same for Sharon.

Respectfully,
Pret Bjorn, RN

-----Original Message-----
From: Avi Roy Shapira [  <mailto:avir@bgumail.bgu.ac.il>
mailto:avir@bgumail.bgu.ac.il]
Sent: Monday, February 11, 2002 9:40 AM
To: trauma-list@trauma.org
Subject: Perineal trauma

A twenty year old girl was shot in a "drive by" terrorist attack. The
weapon used was an AK-47 automatic.

One bullet shattered left elbow with the brachial artery. One entered the
Left thigh, at the groin, and traveled to the popliteal fossa, tearing
the politeal vein just above the knew, and damaging the artery enough to
require an interposition graft. We recovered the bullet from the fossa. It
was largely intact.

A third bullet, entered the posterior wall of the vagina, at the
introitus, shattered the rectum, and the perineum.  I retrieved the steel
core of the bullet from the hollow of the sacrum, where the presacral
venous plexus was bleeding. It was just lying there.  The metal jacket was
gone.

There is really no anus, and no sphincter. They might have just
evaporated.

Anterior elements are preserved (most of the vagina, urethra, labia minor
and clitoris) no intra-abdominal or bladder injury.

We packed the sacrum, fixed the arteries with a piece of vein, ex fixed
the elbow, ligated popliteal vein, did generous fasciotomies, and a
sigmoid loop colostomy.

She needed 12 units of blood, but we gave very little crystalloids.

It is now 24h post incident. She is stable, with a bit of SIRS. Removed
the pack today. There is a huge cavity, but no bleeding.

It looks promising in terms of surviving this, and keeping leg and arm.

My question to the group is about subsequent management. How and when
would you consider reconstruction. What about the anus and sphincter?

Avi

==========================================================================
Aviel Roy-Shapira, M.D.  Soroka University Hospital & Dept. of Surgery A.
and Ben-Gurion University Medical School the Critical Care Unit POB 151,
Beer Sheva, Israel

email:avir@bgumail.bgu.ac.il         Fax:972-7-6403260 voice:972-7-6403390

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<DIV>Avi, Sounds like a 
monumental challenge in reconstruction.&nbsp; Especially in a young adult, one 
would assume that the best approach would be methodical and 
multidisciplinary.&nbsp; What are your resources in colorectal and 
gyn?&nbsp;&nbsp;I don't see the need or benefit of&nbsp;rushing, but then, I'm 
no surgeon.&nbsp; I'll follow the responses&nbsp;with 
interest.</DIV>
<DIV>&nbsp;</DIV>
<DIV>There is of course no way to regard 
this case as anything but purely and pathetically preventable.&nbsp; Perhaps 
your patient would consent to Arafat attending each of her surgeries.&nbsp; 
Surely some similarly brutalized Palestinian would do the same for 
Sharon.</DIV>
<DIV>&nbsp;</DIV>
<DIV>Respectfully,</DIV>
<DIV>Pret Bjorn, RN</DIV>
<DIV>&nbsp;</DIV>
-----Original Message----- From: Avi Roy Shapira [<A 
href="mailto:avir@bgumail.bgu.ac.il">mailto:avir@bgumail.bgu.ac.il</A>] Sent: Monday, 
February 11, 2002 9:40 AM To: trauma-list@trauma.org Subject: Perineal 
trauma A twenty year old girl was shot in a "drive by" terrorist 
attack. The weapon used was an AK-47 automatic. One bullet shattered 
left elbow with the brachial artery. One entered the Left thigh, at the 
groin, and traveled to the popliteal fossa, tearing the politeal vein just 
above the knew, and damaging the artery enough to require an interposition 
graft. We recovered the bullet from the fossa. It was largely 
intact. A third bullet, entered the posterior wall of the vagina, at 
the introitus, shattered the rectum, and the perineum.&nbsp; I retrieved the 
steel core of the bullet from the hollow of the sacrum, where the 
presacral venous plexus was bleeding. It was just lying there.&nbsp; The 
metal jacket was gone. There is really no anus, and no sphincter. They 
might have just evaporated. Anterior elements are preserved (most of 
the vagina, urethra, labia minor and clitoris) no intra-abdominal or bladder 
injury. We packed the sacrum, fixed the arteries with a piece of vein, ex 
fixed the elbow, ligated popliteal vein, did generous fasciotomies, and 
a sigmoid loop colostomy. She needed 12 units of blood, but we gave 
very little crystalloids. It is now 24h post incident. She is stable, 
with a bit of SIRS. Removed the pack today. There is a huge cavity, but no 
bleeding. It looks promising in terms of surviving this, and keeping leg 
and arm. My question to the group is about subsequent management. How and 
when would you consider reconstruction. What about the anus and 
sphincter? Avi ========================================================================== Aviel 
Roy-Shapira, M.D.&nbsp; Soroka University Hospital &amp; Dept. of Surgery 
A. and Ben-Gurion University Medical School the Critical Care Unit POB 
151, Beer Sheva, 
Israel email:avir@bgumail.bgu.ac.il&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
Fax:972-7-6403260 voice:972-7-6403390 -- trauma-list : 
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