Ongom Peter A, Kijjambu Stephen C, Jombwe Josephat
Department of Surgery, School of Medicine, Makerere College of Health Sciences, Makerere University, P O Box 7072 Kampala, Uganda.
J Med Case Rep. 2014 Jan 27;8:29. doi: 10.1186/1752-1947-8-29.
Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet's trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering'; a first of its kind in East Africa.
A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering') of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering' bullet was successfully removed surgically. It had caused no damage to any part of her neck structure.
AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the important decision to extract the entrapped bullet from the patient's neck because it had started to 'wander' and could have caused grave injury over time with further migration. Maxillofacial, plastic, trauma, general and military surgeons, otorhinolaryngologists and emergency physicians can gain from this experience because it calls for a multidisciplinary team approach.
AK-47步枪（一种常见的突击步枪，属于冲锋枪类型）造成的头颈部枪伤是撒哈拉以南非洲平民发病和死亡的重要原因。它们可能会对该区域紧密排列的结构造成严重破坏，而且子弹轨迹很难确定。我们报告一例不寻常的枪伤病例，其子弹入口伤口不典型，面部严重受伤，子弹嵌顿在右侧颈动脉鞘内且出现“游走”；这在东非尚属首例。
一名27岁的尼罗特族非洲乌干达女性因意外遭受AK-47步枪枪击而受到复杂创伤，被转诊至乌干达一家三级医院的急诊科。枪伤位于她面部右侧，有一个大的参差不齐的入口伤口，没有出口伤口。先前的基本伤口护理和影像学检查显示她的下颌骨粉碎性骨折，子弹嵌顿在颈部第六和第七颈椎前方。对其伤口进行了标准清创。计算机断层扫描显示子弹明显向头侧移位（“游走”），部分位于第五颈椎前方以及颈动脉鞘内。其他损伤包括她的面神经、三叉神经和中耳。通过手术成功取出了“游走”的子弹。它未对她颈部结构的任何部分造成损伤。
AK-47步枪子弹伤可能表现为异常大的入口伤口，并在撞击区域造成复杂的结构损伤。随后的轨迹难以预测，因此区域检查和影像学检查对于治疗至关重要。子弹可能会留存体内，没有出口伤口。确保气道通畅、控制出血以及识别其他损伤是首要的关键步骤。本病例展示了所有这些干预措施，以及从患者颈部取出嵌入子弹这一重要决定，因为子弹已开始“游走”，随着进一步迁移，随着时间推移可能会造成严重损伤。颌面外科、整形外科、创伤外科、普通外科和军事外科医生、耳鼻喉科医生以及急诊医生都能从这一经验中获益，因为这需要多学科团队协作。
