Role of conservative management in low energy transfer penetrating shotgun abdominal injuries

Background and aims Penetrating abdominal trauma can be caused by a variety of weapons which require different management protocols. After a long era of mandatory laparotomy for abdominal gunshot wounds, the concept of selective laparotomy and conservative management in the form of serial observations has been introduced in some centers. This study aims to assess the feasibility and safety of conservative management and close observation of victims of low energy transfer shotgun penetrating abdominal injury. Methods A prospective cohort study of hemodynamically stable patients who had sustained low energy transfer shotgun injuries to the abdomen who presented to the surgical emergency department of Cairo University Hospitals from May 2016 to January 2019. They were subjected to a conservative management and follow-up protocol. Results A total of 250 patients (167 males and 83 females) were included. The conservative management protocol was successful in 217/250 patients (86.8%), unsuccessful in 22 patients (8.8%) where abdominal exploration was done either open or laparoscopically. Delayed diagnosis of bowel injury occurred in one patient (0.4%). There was one death (0.4%) and abdominal exploration was negative in 10 (4%) patients. Conclusion We recommend this conservative protocol for the victims of low energy transfer penetrating shotgun injuries which may save many patients from the morbidities of unnecessary laparotomy. We accept that the injury pattern may not be sufficiently common in many countries to allow comfort with this non-operative approach.

Blunt major trauma: now two different diseases?

Major trauma in the UK has changed and can now be thought of as two different diseases: the traditional type of high energy transfer major trauma occurring in younger patients, and low energy transfer major trauma (usually an older person falling on one level). The current NHS trauma system is not well set up to treat low energy transfer major trauma – adapting to the changing disease is the next big challenge.

Enhanced Hybrid Differential Evolution for Earth-Moon Low-Energy Transfer Trajectory Optimization

It is known that the optimization of the Earth-Moon low-energy transfer trajectory is extremely sensitive with the initial condition chosen to search. In order to find the proper initial parameter values of Earth-Moon low-energy transfer trajectory faster and obtain more accurate solutions with high stability, in this paper, an efficient hybridized differential evolution (DE) algorithm with a mix reinitialization strategy (DEMR) is presented. The mix reinitialization strategy is implemented based on a set of archived superior solutions to ensure both the search efficiency and the reliability for the optimization problem. And by using DE as the global optimizer, DEMR can optimize the Earth-Moon low-energy transfer trajectory without knowing an exact initial condition. To further validate the performance of DEMR, experiments on benchmark functions have also been done. Compared with peer algorithms on both the Earth-Moon low-energy transfer problem and benchmark functions, DEMR can obtain relatively better results in terms of the quality of the final solutions, robustness, and convergence speed.

Pathophysiology of ballistic trauma

Bullets and other projectiles cause ballistic trauma. Explosions wound by the effect of a blast pressure wave, penetrating fragments propelled by the explosion, the mass movement of gas interacting with the casualty or the environment, and miscellaneous effects. Most blast casualties surviving to hospital care will not have significant pressure wave injury, but some will. Blast fragmentation most commonly resembles other types of low energy transfer ballistic trauma.. The effect of bullets depends on the kinetic energy transferred and the nature of the tissues struck, with energy transfer partly determined by bullet design. Low energy transfer bullets wound by crushing and laceration, limited to the tissues struck. High energy bullets may impart kinetic energy to surrounding tissues, causing a temporary cavity which sucks in debris and damages tissues sometimes well beyond the bullet track. Predicting the extent of devitalization can be difficult at the time of initial inspection. Wound contamination, particularly with soil, may modify the usual conservative approach to initial debridement.