12 Gauge To The Face

SavageGlow · #1 ● 04-28-2024, 04:20 PM

The case involves a 66-year-old man who was found at home by his wife after a suicide attempt using a Franchi 12-gauge pump-action shotgun. The ammunition used was a Winchester single-round ball (commonly used for boar hunting). The man had a known history of depression and had expressed suicidal intentions prior to the event. The patient was promptly assisted and transported to the emergency department.

>>As evidenced by the photographic documentation taken on admission to hospital, the gunshot was fired from below, on the right side of the face, resulting in a large contused and lacerated wound with significant tissue loss and multifragmentary fractures of the facial bones (Fig. 1). Vital signs in the emergency department showed a blood pressure of 130/75 mmHg, an oxygen saturation level (SpO2) of 94%, and a heart rate of 100 beats per minute.

>>A computed tomography (CT) scan of the brain, neck, facial bones, and cervical spine was performed using a multilayer spiral technique, both before and after contrast agent injection. The CT revealed a hemorrhagic contused and lacerated lesion in the right frontal region of the brain. The neck vessels did not show any significant ongoing bleeding. Facial bone reconstructions with bone window settings revealed a fracture of the right mandibular condyle, involving the mandibular angle with bone loss extending to the left hemimandible from the inferior angle to the symphysis. There were also comminuted and multifragmentary fractures involving the hard palate, ethmoid bone, orbital lamina, and left maxillary sinus. Additionally, metallic foreign bodies were observed within the right eye cavity, along with bone fragments from the orbital floor (Fig. 2).

>>Given the condition of the facial bones and the evident respiratory difficulty, the patient was sedated and intubated. Fluid infusion and antibiotic prophylaxis were initiated. Considering the clinical presentation, the patient was urgently taken to the operating room to control the ongoing facial bleeding and perform a temporary tracheostomy.

>>A post-intubation arterial blood gas (ABG) analysis, with a fraction of inspired oxygen (FiO2) at 40%, showed the following results: pH 7.213 (normal range: 7.350–7.450), pCO2 58.3 mmHg, pO2 87.4 mmHg (normal range: 75.0–100.0 mmHg), ctHb 8.6 g/dL (normal range: 12.0–18.0 g/dL), FO2Hb 92.5% (normal range: 94.0–97.0%), and cLac 8.3 mmol/L (normal range: 0.3–2.5 mmol/L).

>>Five days after the initial admission, the patient’s general condition stabilized and surgical reconstruction of the facial bones was carried out with three-dimensional modeled titanium reconstruction plates and meshes. Soft tissue reconstruction was achieved using local flaps. The extensive lacerated-contused wounds provided access to the damaged right mandible and orbito-malar region, which had experienced significant bone loss. Mandibular reconstruction was performed using a plate, and the orbito-maxillo-malar and nasal regions were reconstructed using appropriately modeled and fixed titanium meshes and screws. Necrotic skin flaps were excised, and skin flaps were created. Sliding flaps were used to fill the cutaneous deficits.

>>A postoperative CT scan was performed to confirm the presence of synthesized materials (Fig. 3). The postoperative course was uneventful. The tracheostomy was removed 3 days after the surgery, and oral feeding was gradually reintroduced in the days that followed without oral cavity infection or functional swallowing issues. The patient was discharged from the hospital 10 days after the surgical intervention.

>>Follow-up visits in subsequent weeks showed regular healing and gradual stabilization of scar outcomes and functional outcomes. Six months post-surgery, despite satisfactory wound healing, the patient was offered a facial reconstruction procedure using microvascular free flaps to achieve better aesthetic and functional restoration of the face and facial skeleton (Fig. 4). However, the patient declined the proposed intervention, expressing satisfaction with the results that had already been achieved [6].