Bomb suspect’s wounds as possible clinical scenarios are discussed below:
Although we are not directly involved in the care of the alleged bombing suspect of the Boston Marathon Dzhokar Tsarnaev who was recently apprehended, we are closely following media reports of his arrest and subsequent transfer to the Beth Israel Deaconess Medical Center.
News reports have shown photos of him lying on the grass with his hands apparently cuffed and his shirt pulled up with law enforcement officers working over him. Also photos have been published of him climbing out of the boat under his own power and also of him on a stretcher inside the ambulance on the way to the hospital. He reportedly suffered a gun shot wound to the neck and the leg.
As a trauma surgeon and critical care physician, some possible scenarios of his medical condition and ongoing care can be gleaned from those fragments of news.
First, Beth Israel Deaconess is a first class hospital capable of giving the highest level of care and is well-versed in the types of injuries that the suspect is reported to have suffered. While no trauma surgeon will ever guarantee an outcome, it is highly likely that he will survive his wounds as he arrived with presence of vital signs.
Second, it appears that he was not intubated at the scene, meaning that he did not have emergent airway issues that could have arisen from a gun shot to the more midline structures of the face or neck. The lack of on-scene intubation does not absolutely rule out a devastating midline wound, but lessens the possibility.
Third, despite the fact that he was not intubated (placement of a breathing tube) at the scene, he was almost certainly intubated once he reached the trauma bay. This is standard procedure to “control the airway” with any gunshot wound to the neck or face, if not because of the wound itself, because control is important during the subsequent tests and imaging that are required where patients are heavily sedated or placed in the computer tomography scanner.
Fourth, he likely required transfusion to replace lost blood so likely he received large bore central venous catheters. For wounds with serious gunshot wounds to the neck or face the central lines were likely placed in the subclavian veins or in the femoral vein, depending where the gunshot wound to the leg was.
Fifth, he likely received an oral gastric tube to decompress his stomach contents after he was intubated and sedated and after it was determined there was no injury to his esophagus.
Sixth, there are several scenarios for the management of his neck wounds. Penetrating neck wounds from civilian grade rifles are managed depending on where anatomically they occur and are rated as being sustained in Zone 1, Zone 2, or Zone 3 with general borders being the thoracic inlet, the mid neck, the angle of the mandible.
However wounds to the neck sustained by a high-powered military style rifle such as the ones likely used in the shootout carry an immense amount of energy and generally require formal neck exploration in the operating room to rule out injury to the neck arteries (carotid and vertebral), veins, esophagus, and trachea.
A missed injury to the esophagus in this situation is a devastating complication so great care was no doubt taken with likely direct visualization through a surgical exploration and then likely with endoscopy through the mouth to visualize the inside of the “goose”.
If there was an esophageal injury from a bullet that was not treated for 20 hours, the situation becomes more grave with the rising possibility of mediastinitis or inflammation of the mediastinum, a condition with a high mortality.
In the case of a gunshot wound to the esophagus, it would be debrided with the fashioning of a spit fistula with no attempt at a primary repair. Wide spectrum antibiotics with coverage with anti-fungals would be begun immediately. A Stamm gastrostomy (surgically placed feeding tube through a small incision in the stomach) would most likely be used to effect feeding in the case of esophageal disruption.
Similarly, the airway patency of the trachea was likely directly explored through surgery and then with a bronchoscopy to view the lumen directly from the inside.
Damage to the venous structures of the neck are generally easy to control through direct ligation. Damage to the carotid artery would likely be managed surgically with debridement and then with a patch angioplasty or artery harvested from elsewhere the body or from cadaver artery.
There are also newer techniques such as embolization that can be used in a partial circumferential injury to a neck artery, particularly if the injury is the posterior vertebral artery.
Seventh, the leg gunshot wound can be serious depending on where the wound was sustained. It is more than possible to bleed to death from a femoral artery wound, which runs from the groin through the deep medial leg next to the femur. An injury to the femoral artery is probably less likely as the patient did not completely bleed out.
It appeared that the patient was able to ambulate enough to raise himself up from the bottom of the boat and then swing his leg over the side and straddle himself before hitting the ground. This makes the likelihood of a serious femoral fracture unlikely as it is generally not possible to bear much weight on a fractured femur. Fractures to the tibia (non weight bearing) generally are much simpler to fix than femur fractures.
Gunshots to the lateral part of the leg can result in tissue loss and pain but are rarely life threatening. He will receive tetanus prophylaxis for the leg and the neck wound.
Eighth, the suspect no doubt received a head CT and CT angiogram of his neck to check for injuries or intimal flaps to the verterbral arteries. Injuries to these arteries are difficult to treat surgically and bleeding is controlled through embolization. Intimal tears and flaps are usually treated with anticoagulation.
Ninth, the suspect will likely be kept intubated and sedated for several days on while on the respirator in the intensive care unit. However, once his gunshot wounds have been addressed and his transfusion needs resolved, he will likely improve quickly owing to his youth and apparent good health. He almost assuredly will not be well enough to make a court appearance this weekend.
Finally, while in the ICU he will be at risk for transfusion-related lung injury, ventilator associated pneumonia, deep vein thrombosis, central line related bloodstream infection, and Clostridium difficile infection (infection of bacterial overgrowth of the colon.)