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Shootings: Treatment Tips, Shotgun Injuries, Perfusion Support & Bullet Design
GUNSHOT WOUND TREATMENT TIPS
- Medication administration may be indicated. The decision should be guided by the patient's overall condition and local protocols. For example, if a sober adult patient has been shot in the hand and is experiencing profound pain, analgesia may be appropriate.1,2
- The use of restraints, physical or chemical, may be indicated as well. Restraints may be used to help minimize patient movement or help protect the patient from additional injury. If restraints are used, providers should clearly document the method selected and the reason it was necessary. Frequent reassessment of the patient's overall status is critical.1,2
- When responding to reported gunshot wounds, providers may want to monitor the radio transmissions of other agencies, including local law enforcement. This can keep them updated on scene developments. Providers may be able to communicate directly with other agencies; this can be invaluable in coordinating on-scene activities.
- A paper bag might be placed over the hand(s) of the patient while the patient is being assessed and managed. This can help preserve evidence, such as gunpowder residue, that might be on the hand(s). This is not routinely done in all EMS systems, so check with your system's guidelines.
- Prehospital spinal immobilization in cases of gunshot wounds continues to be discussed in the medical literature. As recently as January, there was an article in the Journal of Trauma that questioned the need for, and even suggested potential harm from, prehospital spinal immobilization of victims of penetrating trauma. Consult your local protocols.3
References
1. Dries DJ. Initial Evaluation of the Trauma Patient. eMedicine, https://emedicine.medscape.com/article/434707-overview.
2. Miglietta MA. Trauma and gunshot wounds: What you need to know to save a life. Tactical Medical Packs, www.tacticalmedicalpacks.com/files/Combat_Tactics_Trauma_article.pdf.
3. Haut ER, Kalish BT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma 68(1): 115-121, Jan 2010.
SHOTGUN INJURIES: THE IMPACT OF PELLET DISPERSAL
Shotguns are a specific type of firearm that deserves special consideration. A shotgun, sometimes called a scattergun, involves a shell that normally contains small spherical pellets, or shot. A combination of items, such as a slugs or flechettes, can also be used.1-5 In contrast to handguns and rifles, shotguns do not have rifled barrels. As a result, shotgun pellets do not spin.6
When a shotgun is fired, the contents of the shell spread apart as they leave the barrel. This disperses the power of the charge. As the pellets' area of distribution increases, the energy in each pellet decreases. This means the energy of any single pellet is lower than if all the energy of a blast were contained in a single pellet or bullet.3 Differences in range (the distance between the firearm and the target) affect the wounding potential of shotgun pellets more than bullets.
At close range, shotgun injuries can be more severe than bullet injuries because damaging amounts of energy are partially dispersed rather than concentrated. When the masses of multiple pellets are combined and spread over a small area, massive destruction can result. In addition, in contact injuries, the mass of the pellets combined with the combustion of gases can cause significant damage. Close-range shotgun injuries are less predictable than those from longer range, with factors such as anatomic location and pellet density influencing them. At greater range, the wider spread and lower velocity of the pellets tends to produce widely separated and superficial injuries that may be painful but not necessarily life-threatening.
References
1. Stanton-Maxey KJ, Bjerke HS. Abdominal Trauma, Penetrating. eMedicine, https://emedicine.medscape.com/article/433554-overview.
2. Evans MB. Gunshot Wound Ballistics. Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, www.bcm.edu/oto/grand/02_12_04.htm.
3. Coustan D. How Shotguns Work. HowStuffWorks, https://science.howstuffworks.com/shotgun11.htm.
4. Denton JS, Segovia A, Filkins JA. Practical pathology of gunshot wounds. Arch Path & Lab Med, Sep 2006, https://findarticles.com/p/articles/mi_qa3725/is_200609/ai_n16717329/pg_3/.
5. University of Utah, Spencer S. Eccles Health Sciences Library. Firearms Tutorial, https://library.med.utah.edu/WebPath/TUTORIAL/GUNS/GUNINJ.html.
6. Wilson AJ. Gunshot injuries: What does a radiologist need to know? RadioGraphics 19, 1,358-68, Sep 1999.
THE RIGHT PERFUSION: FOR VICTIMS OF PENETRATING TRAUMA, SUPPORT IS KEY
Because penetrating trauma may include fluid loss, a key goal of managing a gunshot wound victim is to support perfusion.
Perfusion occurs when there is adequate circulating volume, adequate volume output and effective gas exchange. When all components are working in concert, it is referred to as ventilation-perfusion matching, or V/Q matching. Any factor that influences V/Q matching, such as a gunshot wound to the myocardium, can result in V/Q mismatching, leading to inadequate perfusion.1-4
If hypovolemia begins to develop, several systems react in an effort to maintain the body's homeostasis and V/Q matching. The hematologic system responds by activating coagulation and contracting the bleeding vessels. Platelets begin to form a clot on the bleeding source. The cardiovascular system responds by increasing the heart rate, myocardial contractility and peripheral vasoconstriction. It also redistributes blood to the brain, heart and kidneys and shunts it away from skin, muscles and the gastrointestinal tract. The renal system responds with vasoconstriction of arteriolar smooth muscle and stimulation of aldosterone secretion by the adrenal cortex. Sodium is reabsorbed and water conserved. The neuroendocrine system responds by causing an increase in circulating antidiuretic hormone (ADH). ADH indirectly leads to increased reabsorption of water and salt by the kidneys.1-4
The signs and symptoms of impaired ventilation-perfusion vary and may present subtly in the prehospital setting. Examples can include altered mentation, agitation, loss of radial or brachial pulses, pale/cool/moist skin, tachycardia and tachypnea. Hypotension should be considered a late and ominous finding. Consider the potential for inadequate perfusion, including V/Q mismatching, and include these factors when determining treatment and hospital destination.1-4
References
1. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany, NY: Delmar Thompson Learning, 2002.
2. Dries DJ. Initial Evaluation of the Trauma Patient. eMedicine, https://emedicine.medscape.com/article/434707-overview.
3. Miglietta MA. Trauma and gunshot wounds: What you need to know to save a life. Tactical Medical Packs, www.tacticalmedicalpacks.com/files/Combat_Tactics_Trauma_article.pdf.
4. Chapleau W, Burba A, Pons P, Page D. The Paramedic. Boston: McGraw-Hill, 2008.
BULLET DESIGN: HOW THE DEADLY PROJECTILES DAMAGE THEIR TARGETS
Many bullets consist of lead encased by an external hard shell called a jacket. Most jackets are made of copper. The jacket assists in preventing the lead from deforming when the bullet is fired or strikes its target.1-5 Bullet design varies. A bullet may be designed with a "full-metal" jacket that largely prevents the lead from deforming on impact. Deformation helps retard the bullet's velocity, so this design promotes deeper penetration.1-5 A full-metal jacket design may result in the bullet passing completely through its target rather than remaining inside. Because of this, gunshot wounds involving full-metal jacket bullets may produce less damage than those with bullets that fragment.
A bullet that fragments may "ricochet" inside the body. There are a number of factors that can influence this, including the location of the bullet's entry and the distance between the weapon and the victim when the weapon is fired.1-5
Bullets can have soft and hollow points (see Figure 1), a design that leaves a portion of lead exposed. When this occurs, the bullet fragments and deforms on contact to a blunt-shaped end resembling a mushroom. This new structure can create a permanent cavity up to 2.5 times larger than the original bullet. Compared to full-metal jacket bullets, bullets that fragment penetrate less deeply but can cause more damage.1-5
In most cases bullets are fired from firearms such as handguns or rifles. The barrels of firearms contain spiral grooves. These grooves are referred to as rifling and cause the bullet to spin on its long axis. This effect gives the bullet directional stability for straighter travel and more accuracy.6
References
1. Stanton-Maxey KJ, Bjerke HS. Abdominal Trauma, Penetrating. eMedicine, https://emedicine.medscape.com/article/433554-overview.
2. Evans MB. Gunshot Wound Ballistics. Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, www.bcm.edu/oto/grand/02_12_04.htm.
3. Coustan D. How Shotguns Work. HowStuffWorks, https://science.howstuffworks.com/shotgun11.htm.
4. Denton JS, Segovia A, Filkins JA. Practical pathology of gunshot wounds. Arch Path & Lab Med, Sep 2006, https://findarticles.com/p/articles/mi_qa3725/is_200609/ai_n16717329/pg_3/.
5. University of Utah, Spencer S. Eccles Health Sciences Library. Firearms Tutorial, https://library.med.utah.edu/WebPath/TUTORIAL/GUNS/GUNINJ.html.
6. Wilson AJ. Gunshot injuries: What does a radiologist need to know? RadioGraphics 19, 1,358-68, Sep 1999.
Paul Murphy, MSHA, MA, has administrative and clinical experience in healthcare organizations.
Chris Colwell, MD, is medical director for the Denver Paramedics and an attending physician in the emergency department at Denver Health Medical Center.
Gilbert Pineda, MD, FACEP, is medical director for Rural/Metro (Aurora, CO) and an attending ED physician at The Medical Center of Aurora and Denver Health Medical Center.
Tamara Bryan Murphy, PA-C, MMS, is an emergency department physician assistant with Kaiser Permanente and Centura Health (Denver/Littleton, CO).
