ORIGINAL PAPERS THE USE OF IMPROVISED BULLET MARKERS WITH 3D CT RECONSTRUCTION IN THE EVALUATION OF PENETRATING TRAUMA A Ramasamy, DE Hinsley, AJ Brooks Department of Surgery, Role 2(Enhanced) MedicalTreatment Facility, Camp Bastion Op HERRICK BFPO 792 Introduction Evaluating the path of a bullet or fragment as it passes through the body can be difficult. As they pass through body tissues, projectiles can deflect, deform or tumble and consequently its path may not be straight [1]. On plain radiographs, the path of a wound track is often difficult to ascertain, even in the presence of bone or bullet fragments [2]. Experience from the Johannesburg Trauma Unit has highlighted the use of an unfolded paperclip as an improvised bullet marker that is placed over the wounds prior to X-rays being taken. In addition to supporting initial clinical evaluation, it also serves as a permanent record of the locations of the wounds and can thereby aid the forensic process [3]. Historically, it has been assumed that patients with gunshot wounds (GSWs) or fragment wounds from mines or improvised explosive devices suspected of traversing a major body cavity have sustained visceral injury regardless of whether they manifest physical signs or symptoms. This has previously mandated laparotomy for all abdominal penetrating ballistic wounds. In recent years this dictum has been called to question and with the advent of advanced diagnostic modalities such as multi-detector computed tomography (CT), some authors have advocated a non-operative approach to selected groups of patients [4, 5]. Prior to the current conflicts in Iraq and Afghanistan, military surgical teams have deployed with basic diagnostic equipment in the form of plain radiography and ultrasonography. Since June 2007, a multi-detector CT scanner has been installed at the Role 2(Enhanced) Medical Treatment Facility in Camp Bastion, Op HERRICK. With the introduction of these scanners in the operational environment, we investigated the use of improvised radio-opaque bullet markers in combination with helical volume rendered 3D CT reconstruction in the evaluation of penetrating torso trauma. Method From February 2008, data was prospectively collected on patients undergoing CT scans at the Role 2(Enhanced) Medical Treatment Facility (MTF) in Camp Bastion, Op HERRICK. Casualties who had sustained penetrating ballistic trauma and where the consultant surgeon needed to determine the trajectory of the projectile or rule out intra-cavity injury were included in the study. The torso was defined as the body region extending between the clavicles above and the inferior gluteal crease below. Patients with clinical indications for operation such as haemodynamic instability, peritonitis, blood per rectum, or gross haematuria were taken directly to theatre. An unfolded paperclip was used as a radio-opaque wound marker (Figure 1) and was taped over the wounds prior to CT scanning. CT was performed with a 6-slice multi-detector CT scanner (Phillips, Netherlands) and standardised protocols for chest and abdomen/pelvis were used with the use of intravenous contrast in all cases. A slice thickness of 5mm with a 2.5 mm table index was used routinely. These images were then reconstructed using the EBW workstation (Phillips, Netherlands). All scans were reviewed immediately by the attending consultant general surgeon and reported by a consultant radiologist at the Royal Hospital Haslar, Gosport. For each patient, the clinical outcome following scanning was recorded and included any operative findings. Corresponding Author: Major Arul Ramasamy, MA, MRCS(Glas), MFSEM, RAMC, ST 3 Trauma and Orthopaedics, Army Medical Directorate, Former Army Staff College, Slim Road, Camberley Surrey GU15 4NP Email: arul49@doctors.org.uk JR Army Med Corps 154(4): 239-241 239 Abstract Radio-opaque markers placed over entry and exit wounds, have been used to help evaluate penetrating injuries and provide a permanent record of wound location on plain radiographs. To date there are no published reports of the application of improvised bullet markers in the evaluation of penetrating injuries using computed tomography (CT). We report a series of 4 cases where bullet markers were used in combination with three-dimensional (3D) computerised tomography (CT) to ascertain the path of the bullets and to assess damage to vital structures. We believe that the use of bullet markers in penetrating trauma casualties undergoing CT is valuable in the surgical decision making process and allows planning of surgical approaches. Figure 1. Radio-opaque marker formed from an unfolded paperclip.