Gunshot wounds may encompass a broad range of injuries involving soft tissues, bones, blood vessels and other underlying structures, including vital organs [1]. The extent of the injury and the appearance of the wound will depend on two factors: the velocity of the bullet or missile and the proximity of the weapon at the time of firing. Firstly, bullets are classified as low-velocity (with a speed of < 600 m/s) or high-velocity (> 600 m/s), and high-speed bullets which are more likely to cause deep penetrating injuries [1] [2]. Secondly, studies have divided the appearance of a gunshot wound into four main categories, depending on the distance of the firearm to the body [3]:

• Contact wound - This type of injury will be easily distinguished by the presence of an imprint of the muzzle that is held against the skin at the time of firing, whereas a prominent and wide stellate pattern of the entrance wound as a result of excessive heat, carbon monoxide and the effects of soot on the skin will be observed [3] [4]. Adjacent reddening of the skin is frequent, and the margins of the entrance wound are seared and often black, without a wide zone of soot deposition [3] [4]. The stellate pattern of skin damage in contact wounds is typically seen, but it must be carefully examined, as certain firearms (eg. rifles) may produce an exit wound that has identical macroscopic features [4].

• Near-contact wounds - Contrary to contact wounds, soot deposition around the entrance wound is frequent in near-contact wounds [3] [4]. Moreover, they are likely to occur when the gun is held at an acute angle to the skin, producing an irregular pattern of soot on the skin [3] [4].

• Intermediate and distant wounds - The absence of soot and surrounding redness of the skin will not be present in gunshot wounds that are inflicted at least two feet away from the victim, and are thus termed intermediate and distant wounds [3] [4]. A pathognomonic feature of close-range or intermediate wounds is the presence of skin tattooing, which demarcates the embodiment of gunpowder into the surrounding skin [4]. Conversely, the absence of skin tattooing indicates that the bullet entered the skin from a significant distance [4].

• Bullet Wound

  October 1990, Volume 155, Number 4 Citation: American Journal of Roentgenology. 1990;155: 685-690. 10.2214/ajr.155.4.2119095 ABSTRACT : The nature and severity of a bullet wound depend on the characteristics of the bullet and of the tissues through which [ajronline.org]

  The appearance of the wound lacked the classical characteristics of entrance and exit bullet wounds, but the investigation showed it was due to the ricocheting of a destabilized bullet. [ncbi.nlm.nih.gov]

  Well, the new XStat Rapid Hemostasis System, better known as the bullet wound tampon, is designed to make this a much easier task for first responders to accomplish. Check out this awesome video to learn more about the bullet wound tampon. [wideopenspaces.com]

  Cleanse wound as early as possible to use flap me(...) - NARA - 45498765.jpg 9.182 6.299; 19,31 MB Medical Department - Treatment - Rifle bullet wound of the buttocks, illustrating extensive loss of soft tissue. [commons.wikimedia.org]

• Pallor

  Observing the pallor, the upturned eyes, the gasping respiration, and the total unconsciousness, I, with uplifted hands, exclaimed, 'My God, Swaim! The President is dying!' Turning to the servant, I added, 'Call Mrs. [eyewitnesstohistory.com]

• Cesarean Section

  We report here a fetus, who was delivered via cesarean section in 32th gestational week from a 37-year-old mother and sustained multiple gunshots. [ncbi.nlm.nih.gov]

• Incontinence

  METHODS: A 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. [ncbi.nlm.nih.gov]

• Urinary Incontinence

  METHODS: A 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. [ncbi.nlm.nih.gov]

• Foot Drop

  Left foot drop was observed on follow up and the patient was discharged with no further complication. [ncbi.nlm.nih.gov]

• Encephalopathy

  Transmissible spongiform encephalopathies (TSE), also known as prion diseases, are characterized by rapid and fatal neurological decline. [ncbi.nlm.nih.gov]

Immediate inspection of the wound and assessment of the presence of an exit wound is the first important step in the diagnostic workup and it is necessary for determining further care. The shape of the wound, its pattern, borders, as well as the presence (or absence) of soot are essential steps, while history taking (if possible from the patient or from accompanying persons) is equally important. After a full clinical workup, imaging studies in the form of plain radiography, computed tomography (CT) and ultrasonography need to be employed, in order to evaluate the extent of tissue injury, including the subcutaneous tissues, blood vessels, bones and vital organs [2] [5] [6] [7]. Although some authors have concluded that the potential risks of using magnetic resonance imaging (MRI) as an imaging method are significantly outweighed by its potential benefits, physicians should be cautioned about performing MRI as metallic objects and bullets in the vicinity of important structures could get dislodged and cause secondary injuries [2] [5].

• Pericardial Effusion

  The suspicion of wound heart with an inlet in the heart area (limited by costal awnings down, clavicles top, and mid-clavicular line outside) and pericardial effusion remains a surgical indication. [ncbi.nlm.nih.gov]

1. Seng VS, Masquelet AC. Management of civilian ballistic fractures. Orthop Traumatol Surg Res. 2013;99(8):953-958.
2. Lichte P, Oberbeck R, Binnebösel M, et al. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med. 2010;18:35.
3. Dicpinigaitis PA, Koval KJ, Tejwani NC, Egol KA. Gunshot wounds to the extremities. Bull NYU Hosp Jt Dis. 2006;64(3-4):139-155.
4. Denton JS, Segovia A, Filkins JA; Practical pathology of gunshot wounds. Arch Pathol Lab Med. 2006;130(9):1283-1289.
5. Ro T, Murray R, Galvan D, Nazim MH. Atypical gunshot wound: Bullet trajectory analyzed by computed tomography. International Journal of Surgery Case Reports. 2015;14:104-107.
6. Burg A, Nachum G, Salai M, et al. Treating civilian gunshot wounds to the extremities in a level 1 trauma center: our experience and recommendations. Isr Med Assoc J. 2009;11(9):546-551.
7. Madsen A, Laing G, Bruce J, Clarke D. A comparative audit of gunshot wounds and stab wounds to the neck in a South African metropolitan trauma service. Ann R Coll Surg Engl. 2016;98(7):488-495.