Back of the neck GSW with evidence of other cavity shrapnel calls for prompt evaluation
Yoram Kluger, Rambam Health Care Campus
3 December 2015
Dear Sirs
We read with great interest the manuscript entitled "Gunshot wound without entrance hole: where is the trick?- a case report and review of the literature" by Silvia Ministrini et al(WJS 2015, 10:52)and would like to congratulate the authors for their success in the management of the patient presented.
A back of the neck entry wound indicates an execution style injury.
X-ray or CT scan suggestion of metallic objects in the abdomen or chest should raise the suspicion of yet another brutal and evil act- Trans anal injury inflicting.
Rectal examination and NG tube insertion in these cases may indicate a more complex injury than the obvious one. ATLS® guidelines indicate a thorough and systematic evaluation of the injured. This comprehensive evaluation includes rectal examination as well as a Foley catheter and a naso gastric tube (NG) insertion, all in the appropriate timing and in regard to the patients need and the complex of injury.
Our experience with Gun Shot Wounds (GSW) and shrapnel injuries to the ano- rectal region indicate that blood on rectal examination is a robust sign for injury and an absolute indication for further evaluation and eventually surgery. Our experience also shows that an NG tube may reveal trace of blood if a GS traversed the stomach.In the case presented by the authors thus clinical steps in evaluation and maybe findings were not mentioned.
We strongly recommend adherence to the strict ATLS® guidelines for injured evaluation and would suggest even adding rectoscopy in a "missing entrance" scenario as presented herein.
We think that the "trick" lies in the awareness of the evil ways humans inflict injuries on their comrades or enemies.
World Journal of Emergency Surgery
Back of the neck GSW with evidence of other cavity shrapnel calls for prompt evaluation
3 December 2015
Dear Sirs
We read with great interest the manuscript entitled "Gunshot wound without entrance hole: where is the trick?- a case report and review of the literature" by Silvia Ministrini et al(WJS 2015, 10:52)and would like to congratulate the authors for their success in the management of the patient presented.
A back of the neck entry wound indicates an execution style injury.
X-ray or CT scan suggestion of metallic objects in the abdomen or chest should raise the suspicion of yet another brutal and evil act- Trans anal injury inflicting.
Rectal examination and NG tube insertion in these cases may indicate a more complex injury than the obvious one. ATLS® guidelines indicate a thorough and systematic evaluation of the injured. This comprehensive evaluation includes rectal examination as well as a Foley catheter and a naso gastric tube (NG) insertion, all in the appropriate timing and in regard to the patients need and the complex of injury.
Our experience with Gun Shot Wounds (GSW) and shrapnel injuries to the ano- rectal region indicate that blood on rectal examination is a robust sign for injury and an absolute indication for further evaluation and eventually surgery. Our experience also shows that an NG tube may reveal trace of blood if a GS traversed the stomach. In the case presented by the authors thus clinical steps in evaluation and maybe findings were not mentioned.
We strongly recommend adherence to the strict ATLS® guidelines for injured evaluation and would suggest even adding rectoscopy in a "missing entrance" scenario as presented herein.
We think that the "trick" lies in the awareness of the evil ways humans inflict injuries on their comrades or enemies.
Yoram Kluger MD, FACS
y_kluger@rambam.health.gov.il
Ofir Ben-Ishay MD
o_ben-ishay@rambam.health.gov.il
Division of General Surgery
Rambam Health Care Center
Haifa, Israel
Competing interests
The authors have no competing interest to declare