Kashif Ali Channar1 , Nabeela Riaz2 , Jehan Alam3 , Riaz Ahmed Warriach4 , Abdul Bari5
How to CITE:
Channar KA, Riaz N,Alam J, Warriach RA, Memon AB. An assessment of maxillofacial gunshot injuries and emergency management. J Pak Dent Assoc. 2012; 21(01):12-15.
Firearm injuries constitute a major challenging problem in maxillofacial surgery, causing major deformities of human body, and financial Burden to our society. Violent crimes are the major cause.
Unemployed youth and socioeconomic deprivations are factors which contribute towards violence. There are few important steps in management of head and neck gunshot injuries, obtaining an airway, control hemorrhage, recognizing additional injuries and finally definitive repair facial deformities. The objective of this study was to report the causes, and patterns of maxillofacial gunshot injuries.
A retrospective assessment of patients treated for gunshot injuries at Mayo hospital Lahore from May 2007 to July 2009 and February 2010 to January 2011 at Liaquat University Hospital Hyderabad was conducted , and data was collected with special emphasis on the patient’s demographics ,mode of injury, initial airway management, and bone injuries
The sample consisted of 120 patients. (78.3 %) males, in third and fourth decade of age were the most common group, violent crime (62.5 %) was the predominant cause, and mandible (58.3%) was the most common site of injury.
From this Available information provided in this study, is concluded that violent crime was major cause of facial gunshot injuries. Male gender and young adults were the most commonly victimized patients.
Comminuted mandible fracture, Gunshot injuries, Air way management, violent crimes.
Firearm injuries (FAI) constitute a major challenging problem in maxillofacial surgery, causing major deformities of human body, and financial Burden to our society . The frequency of violent crimes is increasing day by day and FAI injuries in civilians population is also progressively more frequent .In our country the number of deaths mainly by FA weapons is greater than before due to instability in the region and easy availability of all the sophisticated and modern weapons in irresponsible hands .Causes of the gun-shot injuries in this area of world are violent crimes, domestic violence, suicidal attempts, accidental release of bullet, and air shooting The severity of FAI depends on two factors; one the caliber ofweapon used and second is distance from where it is fired. In instance Close range, low velocity gunshot can result in awful functional and aesthetic concerns for the patients .Air way securing is paramount in initial resuscitation. Swelling and Bleeding from the injury may compromise the airway. Airway control with either conservative nonsurgical method like oral air way, an endotracheal tube or when conventional approaches fail, or not possible than surgical methods like cricothrodectomy and tracheostomy is undertaken as early as possible . Hemodynamic resuscitation is of paramount significance preferably performed simultaneously, than thorough patient assessment to rule out concomitant injuries especially cervical spine . Imaging requirement is considered to reach definitive diagnosis The purpose of this study is to highlight the rising incidence and to assess overall presentation, causes and the early management in Gunshot injuries to the maxillofacial region.
A retrospective study was undertaken of all patients treated for gunshot wounds to Maxillofacial region at Mayo hospital Lahore from May 2007 to July 2009, and department of Oral and Maxillofacial surgery Liaquat university hospital Hyderabad from February 2010 to January 2011. The patients with gunshot wounds involving only the neck or with intracranial injuries were excluded. 120 patients met the study criteria. Medical Records of the patients with gunshot injuries to maxillofacial regionwere reviewedwith special emphasis on the patient’s demographics, causes of injury, initial airway management, and bone injuries. The results were analyzed by using SPSS version 17.
A total of 120 patients were identified and were divided in to six groups. Patient age ranged from 6 to 65 years with mean age was 28.8years. Ninety-four (78.3%) patients were males and twenty six (21.7%) patients were females. (Table1&figure 1).
Seventy five (62.5%) patients were injured due to violent crimes, twenty seven(25%) patients injured due to domestic violence, thirteen (10%) due to accidental firearm discharge, while 2 (1.6%) patients had intentionally self-inflicted suicidalwounds. (Table-2)
Of these patients ninety seven (80.8%) did not require emergency airway management while eight (6.7%) patients were intubated and 15(12.5%) patients required surgic al procedure (cri cothyrode ctomy and tracheostomy). (Figure2)
The commonly injured bone was Mandible 58.3%, followed by isolated maxilla fracture recorded in 10% of the cases. 76.7% patients sustained single gunshot wound and 23.3% of the patients had multiple gun-shot wounds and fractures of themaxillofacial region. (Table 3)
It was a retrospective analysis on 120 consecutive maxillofacial gunshot injured patients reported in maxillofacial units.
FAI to the maxillofacial region is not uncommon in Pakistan. Regardless of this, there is relatively little literature discussing presentation and consequences of these FAI. Predominant age groups in our studywere 20 to 40 years. 3rd to 4th decade constituted the main group in this study,which is observed same as in previous studies .An other important finding in our study was two children one with age 6 year and other 8 years (child less than ten years) with Gunshot injuries were noted because of gun storage at accessible area to children and unattended children at their homes caused accidental discharge of firearm.
It appears from our data that majority of our patients were males and a significantly lower percentage of patients were females. The Male to Female ratio was 7.5:1. Our proportion compares favorably with that of previous studies which men are almost seven times more likely than women to sustain fatal or nonfatal firearm-related injuries .This is in contrast with USA where gunshot injuries to facial region have different ratio 4.6:18 .In our society Females appear to be secure because of their household abodes, dedication to husbands and because they hold pleased place even in disputes and enmities. Generally there are increased male victims by firearminjuries throughout the country Violent crimes were the major cause constituting approximately 62.5% of cases. Violent crimes have been reported from homes, workplaces and highways. Civilian gunshotwounds resulting fromarmed robbery attacks like mobile phone,motor bike, and car theft are common. This may be associated to the high rate of unemployment in Pakistan and the lack of successful poverty eradication programmes. Similar results were found in study conducted by Glapa Min 2007 , and he found the violent crimes in 69.1% of patients. The Other causes of gunshot injuries in our setting are domestic violence, accidental discharge of bullets from firearms handled by law enforcement agents, and unattended children at homes and air shooting in the traditional celebrations, and wedding parties. A stray bullet in these celebrations also found in this area and becomes a lethal injury to a person, away from primary site. Awareness programs and prevention of firearm- related injuries, social changes in the developed countries, improvements in understanding of ballistic and injury management have decreased the overall gunshot injuries .Perhaps Suicidal attempts are also one of the cause, accounts less than two percent in our study, rare in this area possibly because of strong religious restriction, can distinguish from developed non Muslim countries where the ratio is high up to fifty percent The initial care of the facial gunshots strictly adheres to the trauma resuscitation. Special consideration requires for airway management in these patents . Warning signs of airway obstruction are indications for establishing an airway. This airway usually is established by endotracheal intubation, emergent tracheotomy or cricothyroidotomy. In our study the all patients required surgical airway had firearm injuries to mandible. Difficulty in gaining an endotracheal in tubation was common indication for surgical airway. In this study, the most dangerous problem was airway compromise. Orotrachealintubations were required in 6.7% and 12.5% required surgical airway. Mask ventilation by oxygen cylinder were used for many patients on initial presentation. Our study compares favorably with Lary Hetal The pattern of facial injury was comparable to that in other studies of gunshot injuries accessibility of the face as a target for gunshot is variable . Gunshot wounds of the face usually present with a variable amount of distortion. Isolated Mandibular gunshot was the common site of bone involvement followed by mandible and maxilla, combined injuries of facial bones were rare. Presentation of multiple bony involvements was detrimental for patient’s management and consequences of these injuries reflection in the patient’s appearance. Results of the study conducted by Motamadietal 2003 and Glapa Metal 2007 was also similar but the contesting results were found in the study by Larry et al 2003 and Amy Yetal where zygomatic bone was the common site of gunshot injuries followed by the mandible.
From this Available information provided in this study, is concluded that violent crime is major cause of facial gunshot injuries.Male gender and young adults are the common victimized patients.
QualityEducation rate could provide base to eradicate crimes. Poverty control programs and arrangement of youth employment and technical training to deprived sections of society and enforcement of law and order is recommended.
Ban on gunshot usage in celebration, parties and marriages is also recommended.
All licensures should be given the lectures on various occasions to improve their morals to not misuse the weapons (be morally and ethically educated along with due training from times to time)
We thank Dr Noor Ahmed Khoso & Dr Jan S. Isaac for editorial assistance.
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