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].

• Prolonged Bleeding

  Scalp wounds bleed profusely and may require prolonged pressure. Position with head and shoulders slightly raised. [danger.mongabay.com]

• Bullet Wound

  Understanding the mechanisms by which bullets disrupt tissue can help physicians to evaluate and treat wounds. [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]

  […] jpg 1.466 × 2.146; 454 KB Medical Department - Treatment - Rifle bullet wound of the buttocks, illustrating extensive loss of soft tissue. [commons.wikimedia.org]

  Bullet wounds can kill a person long after a shooting. [businessinsider.com]

• 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]

• Stridor

  Signs of tracheal injury hoarsenes stridors subcutaneous emphysema dysphonia, or hemoptysis signs of vascular injury expanding hematoma neurologic deficit Penetrating injury to the neck that need urgent management 40. [slideshare.net]

  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]

  The symptoms often include fatigue, malaise, joint pain, headaches, nausea, vomiting, constipation and changes in memory, behavior and attention span. 24-27 Consequently, when a lead fragment is within a joint, the excision of the fragment is essential [podiatrytoday.com]

• Thrombosis

  We report the case of a gunshot wound injury to the occipital region with retained bullet fragment in the confluence of the sinuses causing traumatic sinus venous thrombosis. [ncbi.nlm.nih.gov]

   Precedes the cavitation phenomena  Not like the shock wave it does not have the characteristic or velocity of the shock wave produced by an explosion  Transmitted through fluid filled structures like blood vessels causing endothelial damage and thrombosis [slideshare.net]

  Besides the laryngoscopy a CT angiography can uncover injuries of relevant organs (trachea, larynx, pharynx) and closed vascular injuries (pseudoaneurysms, thrombosis) [ 26 ]. [doi.org]

• Foot Drop

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

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]

If it was after, one might speculate that, having seen the benefit of the use of onion paste compared to other treatments, each treatment used on several men, Paré decided to use the burnt face to provide a comparison of a different kind, of the two treatments [jameslindlibrary.org]

We cannot tell whether it occurred before or after the treatment at Villane; if it was after, one might speculate that, having seen the benefit of the use of onion paste compared to other treatments, each treatment used on several men, Paré decided to [web.archive.org]

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]

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]

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]

Etiology Gunshot wounds, considered high-velocity projectiles, are the most common cause (64%) of penetrating abdominal trauma, followed by stab wounds (31%) and shotgun wounds (5%). Penetrating abdominal trauma may result from urban violence. [emedicine.medscape.com]

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]

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]

Authors — Ecker, R. et.al eMedicine, Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology, 2009, and Penetrating Head Trauma, 2009. [aans.org]

Biophysics and pathophysiology of penetrating injury. In: Ryan JM, Rich NM, Dale RF, Morgans BT, Cooper GJ, editors. Ballistics trauma, clinical relevance in peace and war. London: Arnold; 1997. p. 31–46. Google Scholar 40. Sellier KG, Kneubuehl BP. [doi.org]

We are not advocating for physicians to become crime fighters, we are interested in public safety and injury prevention. [cmaj.ca]

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]

Peter Cummings, University of Washington; Mike Dowden, Bureau of Alcohol, Tobacco, and Firearms; Jeffrey Fagan, Columbia University; Scott Gast, University of Virginia; Susan Ginsburg, Independent Consultant; Robert Hahn, Centers for Disease Control and Prevention [nap.edu]

Centers for Disease Control and Prevention (CDC) in Atlanta. “About 19 children a day die or are medically treated in an emergency department for a gunshot wound in the U.S.,” Fowler said by email. [reuters.com]

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.