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].

• Pain

  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]

  Clawing at his chest he moaned, "This pain, this pain," while suffering a major heart attack. The president died a few minutes later. Garfield's physicians did not serve him well. [eyewitnesstohistory.com]

• Bullet Wound

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

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

  […] en gunshot wound, bullet wound Samanlaisia lauseita Varsi Ei ampumahaavaa Vic, there' s no bullet wound Ampumahaava vatsassa Gunshot wound to the abdomen Siis kaksi ampumahaavaa. That makes two gunshot wounds. [fi.glosbe.com]

  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]

• Swelling

  The doctors then remove the dead tissue and clear the area to relieve the imminent swelling. Otherwise, the swelling would have no outlet and come out at the base, which often leads to fatal consequences. [scienceabc.com]

  The swelling is still pretty bad. I kept it propped up really high overnight. The swelling isn't as bad as it was last night, but it still looks bad. My knee and the area above is huge. I can actually bend my knee! The ankle is still really stiff. [negligentdischarge.com]

  This helps reduce swelling. You may need to do this while sitting or lying down. You can use pillows to prop up the area. If your provider says it is OK, you may use an ice pack on the bandage to help with swelling. [medlineplus.gov]

  Monitor your wound for signs of infection such as redness, swelling, or pus. Get support. It is normal to have difficult and unexpected feelings after a GSW. You may have feelings such as anger, depression, fear, or anxiety. [drugs.com]

• Hunting

  We discuss the case of a 19-year-old young man who received a diagnosis of chronic lead toxicity (serum lead concentration 51 μg/dL) 5 weeks after a hunting accident. [ncbi.nlm.nih.gov]

  You can read more great hunting articles by John McAdams on his hunting blog. Follow him on Twitter @TheBigGameHunt. NEXT: Armed Grandma Chases Robbers from California Jewelry Store [wideopenspaces.com]

  Early Thanksgiving morning of last year a healthy, large man, aged 42, while hunting, was accidently shot in the left buttock with a 22 rifle. [jamanetwork.com]

  CBC News reports that Wilf Lloyd, a 56-year-old taxidermist from Cranbrook, British Columbia, had been hunting elk with son-in-law Skeet Podrasky when the pair stumbled upon the bear just south of Fernie, B.C. [outsideonline.com]

• Weakness

  Relevant Paper(s) Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses Ritchie AJ and Harvey CF, 1990, UK 64 patients (116 wounds) with gunshot and blast injuries GA for exploration and pull-through [bestbets.org]

  These feelings are not signs of weakness. [medlineplus.gov]

  On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. [orthobullets.com]

• Vomiting

  Lead toxicity in adults is characterized by nonspecific symptoms of abdominal pain, vomiting, constipation, fatigue, and weight loss. [ncbi.nlm.nih.gov]

  You have nausea or are vomiting. You have questions or concerns about your condition or care. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. [drugs.com]

  Warning signs of internal bleeding include: Decreasing alertness Nausea/vomiting Weak pulse Lowering blood pressure, or faster and faster pulse. Important Note These treatments for gunshot wounds are complicated and require advanced knowledge. [thesurvivaldoctor.com]

  - Internal bleeding is very serious and often the only effective treatment is surgery - Signs of internal bleeding include firmness in the abdomen after injury, vomiting blood, blood in urine or feces, large bruises over the flank or abdomen, pale skin [danger.mongabay.com]

• Nausea

  You have nausea or are vomiting. You have questions or concerns about your condition or care. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. [drugs.com]

  Warning signs of internal bleeding include: Decreasing alertness Nausea/vomiting Weak pulse Lowering blood pressure, or faster and faster pulse. Important Note These treatments for gunshot wounds are complicated and require advanced knowledge. [thesurvivaldoctor.com]

  Most anesthesiologists favored halothane, with its rapid action, ease of administration, nonflammability and applicability 56 to all cases; also, it did not produce nausea and did not mask critical drops in blood volume. [web.archive.org]

  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]

• Choking

  Community Lahav Peled, May 10, 2019 A responder’s preparations and sacrifices pay off when he rescues a choking victim. [emsworld.com]

  Make sure the blood doesn’t choke the person. You can have a conscious person sit up and lean forward, or turn an unconscious person on their side and bend the top knee forward to keep them that way. [thesurvivaldoctor.com]

• Hypotension

  Hypotension alone increases mortality in severe TBI from 27% to 60%. Hypoxia, in addition to hypotension, is associated with a mortality of 75%. [lifeinthefastlane.com]

  Damage control resuscitation principles include early implementation of massive transfusion protocols with fixed blood product ratios, avoidance of large-volume crystalloid administration, and appropriate use of permissive hypotension. [emedicine.medscape.com]

  Patients are frequently young and fit so compensate well until in extremis - tachycardia may be delayed and hypotension suggests very marked blood loss.Obtain good intravenous access as soon as possible. If possible, secure bleeding vessels. [patient.co.uk]

• Weak Pulse

  Warning signs of internal bleeding include: Decreasing alertness Nausea/vomiting Weak pulse Lowering blood pressure, or faster and faster pulse. Important Note These treatments for gunshot wounds are complicated and require advanced knowledge. [thesurvivaldoctor.com]

• Fear

  Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). [ncbi.nlm.nih.gov]

  You may feel shock, fear for your safety, depression, or anger as a result. These are completely normal feelings for someone who has been through a traumatic event. These feelings are not signs of weakness. [medlineplus.gov]

  You may have feelings such as anger, depression, fear, or anxiety. You may have nightmares or continue to think about what has happened. Talk to your healthcare provider if you have any of these feelings. Treatments are available to help you. [drugs.com]

  Thus she remained for more than an hour, gazing upon the lifeless features, when Colonel Rockwell, fearing the effect upon her health, touched her arm and begged her to retire, which she did." References: Bliss, D. [eyewitnesstohistory.com]

• Self-Inflicted Wound

  Make sure that patients with self-inflicted wounds have counseling and support before and after the discharge. [medical-dictionary.thefreedictionary.com]

• Stroke

  The Neuro-ICU cares for patients with all types of neurosurgical and neurological injuries, including stroke, brain hemorrhage, trauma and tumors. [neurosurgery.ucla.edu]

  Stroke 1986;17:1317–9. PubMed Google Scholar 72. Smith AS, Hurst GC, Duerk JL, Diaz PJ. MR of ballistic materials: imaging artifacts and potential hazards. AJNR 1991;12:567–72. PubMed Google Scholar 73. [link.springer.com]

  […] gas operation system AK-47 long-stroke gas operation system M16 direct impingement gas system The AK-47 has always enjoyed a reputation for rugged reliability and has a malfunction rate of one per 1000 rounds fired. [255] [256] It uses a long-stroke [en.wikipedia.org]

• Seizure

  Evaluation of most GSWs requires appropriate imaging studies followed by proactive treatment against infection, seizure, and increased intracranial pressure. [ncbi.nlm.nih.gov]

  When President Kennedy was struck in the head by the bullet, his body went into violent convulsions not unlike seizures. This is what caused the President to fall backwards and to the left. [web.archive.org]

  […] head trauma is fatal about 90 percent of the time, with many victims dying before arriving at the hospital For victims who survive the initial trauma, about 50 percent die in the emergency room About 50 percent of surviving patients will suffer from seizures [aans.org]

• 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]

  Everybody else, on the other hand, can and will die from a gunshot wound that so much as grazes their psychic aura. [cracked.com]

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].

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]

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]

The Relationship Between Mechanisms of Wounding and Principles of Treatment of Missile Wounds. Wound ballistics. [wheelessonline.com]

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]

[…] 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]

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]

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]

The threat of blood loss is not unique to Lavery: It’s the number one preventable cause of death on the battlefield. [wired.com]

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]

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.