title: Stratification of risk to the surgical team in removal of small arms ammunition implanted in the craniofacial region: case report.
abstract: In cases of penetrating injury with implantation of small arms ammunition, it can often be difficult to tell the difference between simple ballistics and ballistics associated with unexploded ordnances (UXOs). In the operative environment, where highly flammable substances are often close to the surgical site, detonation of UXOs could have catastrophic consequences for both the patient and surgical team. There is a paucity of information in the literature regarding how to evaluate whether an implanted munition contains explosive material. This report describes a patient who presented during Operation Enduring Freedom with an implanted munition suspicious for a UXO and the subsequent workup organized by Explosive Ordnance Disposal (EOD) Company prior to surgical removal. Clinical risk factors for UXOs include assassination attempts and/or wartime settings. Specific radiological features suggestive of a UXO include projectile size greater than 7.62-mm caliber, alterations in density of the tip, as well as radiological evidence of a hollowed-out core. If an implanted UXO is suspected, risks to the surgical and anesthesia teams can be minimized by notifying the nearest military installation with EOD capabilities and following clinical practice guidelines set forth by the Joint Theater Trauma System.
authors.affiliation: Department of Neurological Surgery, David Grant Medical Center, Travis AFB, Davis, California;
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Forbes
authors.affiliation: United States 47th OD CO (EOD), Fort Hood, Killeen, Texas;
authors.forename: Ian
authors.initials: I
authors.lastname: Laughlin
authors.affiliation: Department of Radiology, San Antonio Military Medical Center, Lackland AFB, San Antonio, Texas;
authors.forename: Shane
authors.initials: S
authors.lastname: Newberry
authors.affiliation: Department of Oral Maxillofacial Surgery, Tripler Medical Center, Honolulu, Hawaii;
authors.forename: Michael
authors.initials: M
authors.lastname: Ryhn
authors.affiliation: Department of Surgery, University of Maryland, CSTARS-Baltimore RA Cowley Shock Trauma, Baltimore, Maryland; and.
authors.forename: Jason
authors.initials: J
authors.lastname: Pasley
authors.affiliation: Department of Otolaryngology, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Texas.
authors.forename: Travis
authors.initials: T
authors.lastname: Newberry
mesh_terms: D005004:Ethmoid Bone / Q000293:injuries* / Q000601:surgery*; D005260:Female; D005547:Foreign Bodies / Q000601:surgery*; D006801:Humans; D011247:Pregnancy; D018570:Risk Assessment; D014948:Wounds, Gunshot / Q000601:surgery*; D055815:Young Adult
keywords: ACH = advanced combat helmet; CJTH = Craig Joint Theater Hospital; EOD = Explosive Ordnance Disposal; IOTV = improved outer tactical vest; UXO; UXO = unexploded ordnance; implanted projectile; small arms ammunition; traumatic brain injury; unexploded ordnance