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Gunshot Wounds of the Female Breast: A Risk fc Intra-abdominal Injury
Abstract
We report the results of a clinical study of female patients sustaining gunshot wounds to a breast. Thirteen homicides were reviewed by the Fulton County Medical Examiner. A prospective series of patients treated by the Grady Memorial Hospital Trauma Service included eight additional cases. Ten (48%) of the combined series of 21 patients had significant intra-abdominal injury; of these, five (24%) had injuries confined to the abdomen as a result of a missile striking a breast. A wound pattern consisting of a superior breast entrance wound, an inferior breast exit wound, and an inframammary thoracoabdominal reentry wound was noted in five patients, four of whom had intra-abdominal injuries and three only intra-abdominal injuries. Careful examination for this wound pattern should alert the clinician to the possibility of intra-abdominal injury. One should anticipate a 50% incidence of intra-abdominal injury in female patients sustaining gunshot wounds to a breast.
... Gunshot wounds have high rates of morbidity and mortality (1). Generally, breast traumas occur concurrently with chest wall, lungs and abdominal wounds (1,2). Isolated breast injury is very uncommon (3). ...
... Therefore, gunshot traumas are generally encountered as multiple organ traumas. Breast wounds occur together with intraabdominal organ damage at a rate of 50%, and less frequently with chest wall and lung wounds (2). Isolated breast wound is very uncommon. ...
... Gunshot wounds have high rates of morbidity and mortality (1). Generally, breast traumas occur concurrently with chest wall, lungs and abdominal wounds (1,2). Isolated breast injury is very uncommon (3). ...
... Therefore, gunshot traumas are generally encountered as multiple organ traumas. Breast wounds occur together with intraabdominal organ damage at a rate of 50%, and less frequently with chest wall and lung wounds (2). Isolated breast wound is very uncommon. ...
Gunshot injuries form a major part of trauma but isolated breast injury due to gunshot is rare. Presented is a 40-year-old female with gunshot (pellets) injury of the breast. Initial surgeries to extract pellets resulted in partial amputation of the breast with surgical site infection. Management of this patient presented a dilemma in judgment of treatment in view of the effects of foreign bodies in the breast.
... Only three of these patients had wounds confined to only the breast. 2 Management of high-impact penetrating injuries can be more complex than other soft tissue injuries elsewhere because of the implications on cosmesis and future reconstructive options. We present the course, management, and cosmetic results of one patient treated at our Level I trauma center who sustained a significant ballistic injury to the right breast. ...
Background
Traumatic breast injuries that require surgical intervention are rare and incompletely studied. The study objective was to define the incidence, mechanism/burden of injury, interventions, and outcomes after breast injuries requiring surgery nationally.
Methods
All patients with breast trauma necessitating surgery were identified from the National Trauma Data Bank (NTDB) (2006-2017) using ICD-9 and -10 codes, without exclusions. Demographics, injury mechanism/severity, procedures, and outcomes (mortality, hospital length of stay [LOS, days], ICU LOS, and AIS >1 in >1 body regions, defining multisystem trauma) were compared with ANOVA or Chi-squared tests, as appropriate.
Results
In total, 899 patients (.01% of NTDB) met study criteria. Median age was 41 years and most patients were female (n = 802, 89%). Penetrating trauma was the most common injury mechanism (n = 395, 44%), followed by blunt trauma (n = 369, 41%) and burns (n = 135, 15%). Median ISS was higher after blunt trauma than penetrating trauma or burns (10 vs 5 vs 4, P < .001). Laceration repair/mastotomy was the most common procedure among penetrating (n = 354, 90%) and blunt (n = 265, 72%) trauma patients, while mastectomy was the most common after burns (n = 126, 93%). Breast procedures varied significantly by mechanism (P < .001).
Conclusion
Breast injuries requiring surgery are uncommon. Most occur following penetrating trauma, although injury severity is highest after blunt trauma and mortality is highest after burns. Procedure type, injury severity, and outcomes varied significantly by mechanism of injury, implying that breast trauma should be considered within the context of injury mechanism. These findings may assist with prognostication after breast trauma necessitating surgical intervention.
Forty-four acute cases of thoracoabdominal injuries in civilian practice are presented. Injury to multiple abdominal organs occurred in 50 per cent. The mortality in those with multiple organ injuries was 33 per cent whereas among those with injury to a solitary organ it was 4.5 per cent. The liver was injured in 61 per cent of cases. Although intercostal tube drainage (50 per cent) usually suffices in the management of the chest injury, thoracotomy was indicated in a number of cases. We advocate preservation of the thoracoabdominal barrier, by making a separate thoracic and abdominal wound, to prevent thoracic contamination, diaphragmatic hernia, and to achieve a thorough abdominal exploration. The total complication rate is 25 per cent. There were nine deaths (20 per cent) in the entire series, eight of which were directly related to the thoracoabdominal injury, yielding a corrected mortality of 18 per cent. One patient died from a separate gunshot wound to the brain.
Our experience indicates a continued rising incidence of gunshot wounds of the chest in the United States. During the past 4 1/2 years, 250 consecutive cases were treated at the King-Drew Medical Center in Los Angeles. Ninety per cent presented with a haemothorax or haemopneumothorax. Pneumothorax alone was present in only 3 per cent of cases. Twenty per cent had associated intra-abdominal injuries, involving mostly the diaphragm, liver, spleen and the gastrointestinal tract. Eighty per cent were treated with tube thoracostomy and among these there were 2 deaths, neither being related to the chest injury. About 16 per cent underwent thoracotomy with a mortality of 12.8 per cent, all the deaths being caused by severe cardiac wounds. The overall mortality was 2.8 per cent. The complication rate was 5.3 per cent, most complications occurring in patients with associated intra-abdominal and spinal cord injuries. The average period of hospitalization was 6.5 days. The management plan and the indications for the two courses of therapy are discussed.
This study of the records of 193 consecutive patients admitted for penetrating anterior chest wounds was carried out to specifically define the need for emergent thoracotomy or laparotomy. The mechanism of injury was a stab wound in 119 patients and a gunshot wound in 74 patients. Seventy-three of the patients (38 percent) required either early thoracotomy (21 percent) or laparotomy (17 percent). In the upper chest region, 83 percent of the operations were thoracotomies, whereas in the lower chest region, 81 percent were laparotomies. Pericardial tamponade, chest tube output, and hypovolemic shock comprised 91 percent of the decisive signs for thoracotomy. The predominant reason for laparotomy was diagnostic peritoneal lavage (63 percent of patients). Plain abdominal roentgenograms were helpful to confirm diaphragmatic missile traverse. Our findings support selective operative management of anterior chest wounds as guided by injury mechanism and entrance location.
Exsanguination may be presumed in pale, mottled, unresponsive trauma victims with no palpable pulse nor spontaneous respirations with noncranial penetrating wounds. Under ideal circumstances, those victims initially witnessed to have some signs of life can be successfully revived in 5 to 25% of cases. The chance for a successful outcome influences the decision to initiate resuscitation and depends on the mode of injury, anatomic location of the wound, and elapsed time until presentation as well as the organization of the available facilities and personnel. The resuscitative algorithm for presumed exsanguination is markedly different from the ACLS guidelines for cardiogenic arrest and requires some degree of surgical expertise. After confirming the witnessed cardiopulmonary arrest from presumed exsanguination, the four phases of resuscitation are restoring central oxygenation, controlling internal hemorrhage, re-establishing spontaneous cardiac function, and definitively repairing the injury. Regardless of the type or location of the noncranial penetrating injury, these phases must be accomplished sequentially to minimize the risks of cerebral and cardiac anoxia.
Fifty-one patients with penetrating wounds of the thorax at or below the 4th intercostal space were evaluated with peritoneal aspiration and lavage. Nineteen gunshot wound and 32 stab wounds were studied and there was a 22% incidence of diaphragmatic penetration and/or intra-abdominal injury. There were ten true positive and one false positive study. There were 39 true negative and one false negative lavage. Peritoneal aspiration and lavage is a test of high sensitivity (91%) and specificity (98%). It has proven to be a useful screening technique in patients with penetrating wounds of the thorax. Peritoneal aspiration and lavage identify the patients with diaphragmatic penetration and intra-abdominal injury and minimize negative exploration.