General assessment

The ABCs (airway, breathing, circulation) of Advanced Trauma Life Support remain the cornerstone in the treatment of ballistic trauma. After ensuring adequate ventilation, resuscitation with fluid and blood should be initiated early and in most instances continuously and aggressively. However, uncontrolled hypertension may aggravate bleeding, and therefore in thoracoabdominal injuries, where operative control of the bleeding site is needed, 'controlled hypotension' (systolic pressure between 80 and 90 mmHg) may be preferable until the patient is in the operating room. Hypothermia, which can result in rapid and significant metabolic and coagulation defects, should be prevented by heating the resuscitation and operating rooms, warming intravenous fluids and blood products, and performing intraoperative irrigation with warmed fluids. Active rewarming may be achieved by a number of techniques including heating ventilator circuits, rapid infusion devices, continuous arteriovenous rewarming devices, and, occasionally, various forms of bypass. Coagulation defects may also require supplemental platelet and plasma infusions.

All ballistic injuries can result in such severe anatomical and physiological disruption that the goal of surgery is simple ligation of non-life-essential vessels, closure of enteric injuries, packing of bleeding sites, and closure with towel clips or other temporary means. The patient should be transferred to the intensive care unit and aggressively rewarmed and resuscitated. Re-exploration and definitive repair is performed when the patient's condition has improved, usually within 24 to 48 h. Threatened limb loss may have to be accepted, or can be managed by extra-anatomical or retroperitoneal revascularization.

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