Gun shot wounds: Difference between revisions
 
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==Background==
==Background==
*Bullets
*Bullets
**Lead alloy
**Composed of a full or partial metal "jacket" around a lead alloy core
**Tip variation (pointed, flat, hollow)
**Shape depends on caliber and tip type (pointed, flat, hollow, soft)
*High Velocity Bullets (M-16 or 30/06 Springfield)
*General caliber classification
**Very high kinetic energy
**Small (.22, .25)
**Little deformity when fired
**Medium (.32, .38, .357, 9mm)
**Cavitation is principle mechanism of destruction, the dissipation of energy radially away from the bullet as it travels through tissue
**Large (.40, .41, .44, .45, .50)
**Large zone of tissue injury even away from tract
*Common shotgun gauges
*Low Velocity Bullets (.22 long rifle or .45 pistol)
**12-gauge = bore diameter of .729 inches
**Relatively low kinetic energy
**20-gauge = .615 inches
**Deform from friction
*Shotgun pellets, small to large
**Crash injury is priniciple mechanism of damage given projectile tumbling and fragmentation
**Birdshot (shotshells) - many small pellets, large kill spread
*Shotgun
**Buckshot - fewer but larger pellets
**Very high kinetic energy at close range
**Slug, sabots - single large solid slug
**Shells contain several to several hundred hundred pellets
 
**Spread of pellets and rapid energy transfer makes these weapons dangerous
===Types===
[[File:Bullet.png|thumb]]
====High Velocity Bullets====
*Examples: .223 or 30/06 Springfield
*Very high kinetic energy
*Little deformity when fired
*Cavitation is principle mechanism of destruction, the dissipation of energy radially away from the bullet as it travels through tissue
*Large zone of tissue injury even away from tract
 
====Low Velocity Bullets====
*Examples: .22 long rifle or .45 pistol
*Relatively low kinetic energy
*Deform from friction
*Crash injury is principle mechanism of damage given projectile tumbling and fragmentation
 
====Shotgun====
*Very high kinetic energy at close range
*Shells contain several to several hundred hundred pellets
*Spread of pellets and rapid energy transfer makes these weapons dangerous at close range


==Clinical Features==
==Clinical Features==
*Assess for entrance and exit wound
*Assess for number of wounds to help determine if projectile may still present in body
**Exit wound may not follow logical trajectory
**Exit wound may not follow logical trajectory
**May be absent, especially with low velocity GSWs
**Strongly consider not documenting "entrance" vs. "exit" given medicolegal implications if not completely sure
*Missiles refer to fragments of bone or other tissue, secondary to the bullet
*Entrance wound (typical features)
*Refer to specific systems for additional information
**Round, punched out hole
**Marginal abrasion or abrasion ring
**+/- fouling (soot)
**+/- stippling (punctate abrasions from gunpowder impact)
*Exit wound (typical features)
**Usually larger (except head)
**Wound edges may be reapproximated
**No marginal abrasion
**Slit-like, stellate, circular
**Irregular due to loss of kinetic energy, bullet deformation, yaw
*Range of fire
**Contact (< 12 inches) → fouling/soot, muzzle stamp (tight contact)
**Intermediate (2.5-3.5 feet) → +/- fouling, stippling
**Distant (>3.5 feet) → wound only
*Shotgun extrance wounds
**Marginal abrasion, fouling, stippling
**Plastic wad may be found in body if range <5-10 feet
**Close range (<12 inches) may have ~1 inch diameter single hole with fouling
**3 feet - round hole, scalloped edges, stippling
**4 feet - round hole, scalloping, satellites
**Distant (>10 feet) - pellet spread


==Region Specific Information==
===Region Specific Information===
*[[Head Trauma (Main)]]
*[[Head Trauma (Main)]]
*[[Neck Trauma]]
*[[Penetrating neck trauma]]
*[[Cardiac Trauma]]
*[[Cardiac Trauma]]
*[[Pericardial Effusion]]
**[[Pericardial effusion and tamponade]]
*[[Diaphragm Injury]]
*[[Diaphragm Injury]]
*[[Abdominal Trauma]]
*[[Abdominal Trauma]]
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*[[Spinal Trauma (Main)]]
*[[Spinal Trauma (Main)]]


==Workup==
==Evaluation==
[[File:PMC3369416 crg-0006-0243-g03.png|thumb|For intra-articular retained bullet, consider risk of developing [[lead poisoning]].]]
*ATLS/FAST/Trauma Labs
*ATLS/FAST/Trauma Labs
*CT Scan as needed depending on location
*CT Scan as needed depending on location
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*Ortho consult for bony injuries
*Ortho consult for bony injuries
*Neuro/OMF/ENT as needed
*Neuro/OMF/ENT as needed
*Removal if intraarticular, with case reports of lead toxicity<ref>Lu K et al. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med. 2015 Jul; 16(4): 489–496.</ref>
===Prophylactic Antibiotics===
*Infection after gunshot injury is a rare complication
*No prophylactic antibiotics for:<ref>Hot bullet, Dirty Wound? http://wueverydayebm.blogspot.com/2015/02/hot-bullet-dirty-wound.html</ref>
**Soft tissue gun shot wounds
**Non-operative fractures caused by gun shot wounds
*Give prophylactic  for:<ref>Simpson, B. M., Wilson, R. H., & Grant, R. E. (2003). Antibiotic therapy in gunshot wound injuries. Clinical orthopaedics and related research, 408, 82-85.</ref>
**Intra-articular fracture (any type of gun shot wound)
**Fractures caused by high-velocity weapons or shotguns
**Penetration through contaminated hollow viscous (passage through bowel)<ref>Lu K et al. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med. 2015 Jul; 16(4): 489–496.</ref>


==Disposition==
==Disposition==
*OR if significant injuries
*To OR if significant injuries
*Admission/Obs for less concerning injuries
*Admission/Obs for less concerning injuries
*Minor injuries may be discharged
*Minor injuries may be discharged
*GSW Protocol allows lower extremity wounds to be discharged from ED after 9 hours without invasive imaging if they have normal ABIs<ref>Sandjadi, Javid. Expedited treatment of lower extremity gunshot wounds. </ref>
*GSW Protocol allows lower extremity wounds to be discharged from ED after 9 hours without invasive imaging if they have normal ABIs<ref>Sandjadi, Javid. Expedited treatment of lower extremity gunshot wounds.</ref>
 
==See Also==
*[[Missile embolus]]
*[[Wound ballistics]]
*[[Trauma (main)]]


==Sources==
==References==
<references/>
<references/>


[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 18:27, 3 August 2022

Background

  • Bullets
    • Composed of a full or partial metal "jacket" around a lead alloy core
    • Shape depends on caliber and tip type (pointed, flat, hollow, soft)
  • General caliber classification
    • Small (.22, .25)
    • Medium (.32, .38, .357, 9mm)
    • Large (.40, .41, .44, .45, .50)
  • Common shotgun gauges
    • 12-gauge = bore diameter of .729 inches
    • 20-gauge = .615 inches
  • Shotgun pellets, small to large
    • Birdshot (shotshells) - many small pellets, large kill spread
    • Buckshot - fewer but larger pellets
    • Slug, sabots - single large solid slug

Types

Bullet.png

High Velocity Bullets

  • Examples: .223 or 30/06 Springfield
  • Very high kinetic energy
  • Little deformity when fired
  • Cavitation is principle mechanism of destruction, the dissipation of energy radially away from the bullet as it travels through tissue
  • Large zone of tissue injury even away from tract

Low Velocity Bullets

  • Examples: .22 long rifle or .45 pistol
  • Relatively low kinetic energy
  • Deform from friction
  • Crash injury is principle mechanism of damage given projectile tumbling and fragmentation

Shotgun

  • Very high kinetic energy at close range
  • Shells contain several to several hundred hundred pellets
  • Spread of pellets and rapid energy transfer makes these weapons dangerous at close range

Clinical Features

  • Assess for number of wounds to help determine if projectile may still present in body
    • Exit wound may not follow logical trajectory
    • Strongly consider not documenting "entrance" vs. "exit" given medicolegal implications if not completely sure
  • Entrance wound (typical features)
    • Round, punched out hole
    • Marginal abrasion or abrasion ring
    • +/- fouling (soot)
    • +/- stippling (punctate abrasions from gunpowder impact)
  • Exit wound (typical features)
    • Usually larger (except head)
    • Wound edges may be reapproximated
    • No marginal abrasion
    • Slit-like, stellate, circular
    • Irregular due to loss of kinetic energy, bullet deformation, yaw
  • Range of fire
    • Contact (< 12 inches) → fouling/soot, muzzle stamp (tight contact)
    • Intermediate (2.5-3.5 feet) → +/- fouling, stippling
    • Distant (>3.5 feet) → wound only
  • Shotgun extrance wounds
    • Marginal abrasion, fouling, stippling
    • Plastic wad may be found in body if range <5-10 feet
    • Close range (<12 inches) may have ~1 inch diameter single hole with fouling
    • 3 feet - round hole, scalloped edges, stippling
    • 4 feet - round hole, scalloping, satellites
    • Distant (>10 feet) - pellet spread

Region Specific Information

Evaluation

For intra-articular retained bullet, consider risk of developing lead poisoning.
  • ATLS/FAST/Trauma Labs
  • CT Scan as needed depending on location
  • X-ray if bony injury suspected
  • CTA if vascular injury suspected

Management

  • Trauma consult depending on location and extent of wound
  • Ortho consult for bony injuries
  • Neuro/OMF/ENT as needed
  • Removal if intraarticular, with case reports of lead toxicity[1]

Prophylactic Antibiotics

  • Infection after gunshot injury is a rare complication
  • No prophylactic antibiotics for:[2]
    • Soft tissue gun shot wounds
    • Non-operative fractures caused by gun shot wounds
  • Give prophylactic for:[3]
    • Intra-articular fracture (any type of gun shot wound)
    • Fractures caused by high-velocity weapons or shotguns
    • Penetration through contaminated hollow viscous (passage through bowel)[4]

Disposition

  • To OR if significant injuries
  • Admission/Obs for less concerning injuries
  • Minor injuries may be discharged
  • GSW Protocol allows lower extremity wounds to be discharged from ED after 9 hours without invasive imaging if they have normal ABIs[5]

See Also

References

  1. ↑ Lu K et al. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med. 2015 Jul; 16(4): 489–496.
  2. ↑ Hot bullet, Dirty Wound? http://wueverydayebm.blogspot.com/2015/02/hot-bullet-dirty-wound.html
  3. ↑ Simpson, B. M., Wilson, R. H., & Grant, R. E. (2003). Antibiotic therapy in gunshot wound injuries. Clinical orthopaedics and related research, 408, 82-85.
  4. ↑ Lu K et al. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med. 2015 Jul; 16(4): 489–496.
  5. ↑ Sandjadi, Javid. Expedited treatment of lower extremity gunshot wounds.
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