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Gunshot Wound

Gunshot Wounds

Gunshot wounds, depending on the velocity of the missile fired and the proximity of the weapon, cause a variable degree of superficial and penetrating injury, which may be life-threatening if major blood vessels or organs are affected. A careful clinical inspection of the entrance wound, determining if an exit wound is present, and appropriate imaging studies are necessary components in the diagnostic workup.


Presentation

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]
  • 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]
  • 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]
  • Intra-articular bullet wounds have been found to cause both local and systemic consequences, in particular, when retained over many years.[ncbi.nlm.nih.gov]
  • 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]
Hypoventilation
  • Patients who are apnoeic or hypoventilating require bag and mask ventilation prior to tracheal intubation and ventilation. Insert a chest drain if there is suspected damage to the lung, bronchus, or chest wall.[patient.co.uk]
Stridor
  • Hard signs include airway compromise, unresponsive shock, diminished pulses, uncontrolled bleeding, expanding hematoma, bruits/thrill, air bubbling from wound or extensive subcutaneous air, stridor/hoarseness, neurological deficits.[en.wikipedia.org]
Constipation
  • Lead toxicity in adults is characterized by nonspecific symptoms of abdominal pain, vomiting, constipation, fatigue, and weight loss.[ncbi.nlm.nih.gov]
Pulsus Paradoxus
  • Pulsus paradoxus may be noted as with constrictive pericarditis. The JVP may not be visible if there is hypovolaemia. Pericardial aspiration is a useful diagnostic tool and may be a life-saving treatment.[patient.co.uk]
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]
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]
Foot Drop
  • Left foot drop was observed on follow up and the patient was discharged with no further complication.[ncbi.nlm.nih.gov]
Complex Regional Pain Syndrome Type II
  • Three months after, he presented to an outpatient pain management clinic right arm pain and was diagnosed with complex regional pain syndrome type II (CRPS II).[ncbi.nlm.nih.gov]
Aura
  • Consisting of a soft pillow-sized pad that you slip under your sheet and a bedside lamp and speaker, the Aura monitors your sleeping patterns (including breathing and heart rates) before waking you at the right point in your sleep cycle with a gentle[independent.co.uk]

Workup

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]
Normal Chest X-Ray
  • Asymptomatic people with a normal chest X-ray can be observed with a repeat exam and imaging after 6 hours to ensure no delayed development of pneumothorax or hemothorax.[en.wikipedia.org]

Treatment

  • Traditionally, external fixation has resulted in longer treatment times and the need for revision surgery. Rigid fixation has many proponents because of shorter postoperative treatment times and fewer complications.[ncbi.nlm.nih.gov]
  • Early diagnosis and appropriate treatment are essential.[ncbi.nlm.nih.gov]
  • Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative.[ncbi.nlm.nih.gov]
  • Venous sinus injury, which occurs in a subset of depressed skull fractures, is not typically listed as an indication for surgical treatment due to the potential for major venous hemorrhage associated with surgery near these structures.[ncbi.nlm.nih.gov]
  • The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option. Copyright 2010 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]

Prognosis

  • PURPOSE: To explore the effect of admission physical examination findings, anamnesis, and computed tomography on dural penetration and prognosis in patients with cranial gunshot wound (CGW).[ncbi.nlm.nih.gov]
  • Understanding the trajectory of the bullet path is important in determining prognosis. The brain is divided into two hemispheres made up of four lobes each, with each lobe providing different functions.[aans.org]
  • […] lesion; - intervention is indicated w/ debilitating pain, failure to progress and progression of the lesion while under observation; - with nerve repair better results were seen in the roots C5, C6 and C7 and of the lateral and posterior cords, but prognosis[wheelessonline.com]

Etiology

  • Its etiology can be traumatic or nontraumatic. Traumatic lesion of the thoracic duct occurs after accidents or cardiothoracic surgery. Non-Hodgkin's lymphoma is the most frequent nontraumatic etiology.[ncbi.nlm.nih.gov]
  • Unlike familial or spontaneous CJD, this variant was connected to consumption of cattle contaminated with the prion disease, bovine spongiform encephalopathy.This development increased interest in the etiology of CJD and other TSEs and the risk it presents[ncbi.nlm.nih.gov]
  • Incomplete fractures associated with penetrating trauma: etiology, appearance, and natural history. J Trauma 1988;28:106–9. PubMed Google Scholar 80. Smith HW, Wheatley KK Jr. Biomechanics of femur fractures secondary to gunshot wounds.[link.springer.com]
  • As seen in the United States, gunshot violence has besides its medical importance also an enormous economic impact as the third most costly etiology of injury and the fourth most expensive form of hospitalization [ 4 – 6 ].[doi.org]

Epidemiology

  • LEVEL OF EVIDENCE: Epidemiologic study, level II.[ncbi.nlm.nih.gov]
  • Authors — Ecker, R. et.al eMedicine, Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology, 2009, and Penetrating Head Trauma, 2009.[aans.org]
  • Interpretation of fatal gunshot wounds in post-mortem is fraught and requires expert attention. [ 3 ] Epidemiology Deaths from firearms reflect their availability in various countries.[patient.co.uk]
  • Federal-funded research into firearm injury, epidemiology, violence, and prevention is minimal.[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Being aware of the pathophysiology of penetrating spinal injuries, along with current evidence-based practice, will assist providers in making sound clinical decisions for their patients.[ncbi.nlm.nih.gov]
  • The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients.[ncbi.nlm.nih.gov]
  • Authors — Ecker, R. et.al eMedicine, Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology, 2009, and Penetrating Head Trauma, 2009.[aans.org]
  • PAROLE IN INGLESE CHE FANNO RIMA CON GUNSHOT WOUND Sinonimi e antonimi di gunshot wound sul dizionario inglese di sinonimi PAROLE IN INGLESE ASSOCIATE CON «GUNSHOT WOUND» gunshot wound gunshot wound pathophysiology stomach fatal wounds pictures shoulder[educalingo.com]

Prevention

  • He, therefore, underwent arthroscopic ankle arthrodesis with preoperative chelator therapy to prevent a further increase in blood lead levels secondary to surgical manipulation.[ncbi.nlm.nih.gov]
  • We are not advocating for physicians to become crime fighters, we are interested in public safety and injury prevention.[cmaj.ca]
  • Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield.[ncbi.nlm.nih.gov]
  • The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies.[ncbi.nlm.nih.gov]
  • Initial management is focused on preventing secondary brain injury by preventing hypoxia and hypotension, which have been shown in the context of TBI to be the most important variables affecting outcome.[lifeinthefastlane.com]

References

Article

  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.

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Last updated: 2019-07-11 22:10