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AK-47 to the hip, with rectal blood

Avi Roy Shapira avir at bgumail.bgu.ac.il
Sun May 29 09:26:16 BST 2005


Ken, 

High velocity and cavitation injuries are a myth. See the numerous
publications by Col Fackler on this issue.  They are readily available on
the internet (the best source is:  Wound ballistics. A review of common
misconceptions M. L. Fackler JAMA. 1988;259:2730-2736.)

You can get secondary blast effect, from fragments of bones etc, but in
general, an AK-47 bullet, unlike an M-16 bullet, does not fragment or
deform.

Unfortunately, I treated a number of AK-47 injuries, which are more common
here than handguns. Fact is that a 0.45 slug from a "low velocity" Colt
peacemaker may do more damage, and its tract is more unpredicatable.

We should treat the wound, not the bullet. Extensive debridement of such
wounds does more harm than good.  In the presence of extensive hematoma it
is hard to tell viable from dead muscle, but in general, most of the
muscle will be viable.  

Furthermore, the vessels in this region are really inaccessible sugically,
and as a rule, when you start debriding in this area, you will get
troublesome bleeding, and packing does not work very well
(because there is nothing to pack against). Eventualy, you
will end up in the angio suit trying to embolize. Unless the hematoma is
expanding, it is better to leave it alone. If it is expanding, I agree
with Yoram that angiographic embolization is the way to go.   

Since there is rectal bleeding (I missed that on the original description)
there is no need to do any studies to confirm rectal injury, and diversion
is in order. Since you need to do a laparotomy anyway for the diversion, I
agree that CT is not indicated.  However, based on the trajectory of the
bullet, I will be surprized if you should find any intraabdominal
injuries.

Avi 





 On Sat, 28 May 2005 KMATTOX at aol.com wrote:

> This patient needs to go to the OR, perhaps a quick proctoscopy to document  
> the blood and rectal injury, and have a laparotomy, take care of injuries 
> above  the peritoneal reflection, and as described have a diverting sigmoid  
> colostomy.   At this point he should be closed, rolled over and have  the buttocks 
> wound explored and debrided.
>  
> An AK 47 is a high velocity missile, traveling from 28,000 to 32,000  ft/sec, 
> depending on the load of the powder.   It creates a great deal  of cavitation 
> and as described will have a contaminated soft tissue space both  from the 
> wound and from the enteric injury.   The debrided buttocks  wound should be 
> packed OPEN and taken back to OR for dressing changes daily or  every other day 
> till granulation is seen.    
>  
> The debridment is more important than any antibiotic that you may put him  
> on.   There is NO NEED for rectal washout or placement of presacral  drains.  
>  
> k
> --
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==========================================================================
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 at bgumail.bgu.ac.il         Fax:972-7-6403260 voice:972-7-6403390





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