Gun shot wounds

Background

• Bullets
  • Lead alloy
  • Tip variation (pointed, flat, hollow)
• High Velocity Bullets (M-16 or 30/06 Springfield)
  • Very high kinetic energy
  • Little deformity when fired
  • Cavitation is principle mechanism of destruction, the dissipation of energy radially away from the bullet as it travels through tissue
  • Large zone of tissue injury even away from tract
• Low Velocity Bullets (.22 long rifle or .45 pistol)
  • Relatively low kinetic energy
  • Deform from friction
  • Crash injury is priniciple mechanism of damage given projectile tumbling and fragmentation
• Shotgun
  • Very high kinetic energy at close range
  • Shells contain several to several hundred hundred pellets
  • Spread of pellets and rapid energy transfer makes these weapons dangerous

Clinical Features

• Assess for entrance and exit wound
  • Exit wound may not follow logical trajectory
  • May be absent, especially with low velocity GSWs
• Missiles refer to fragments of bone or other tissue, secondary to the bullet
• Refer to specific systems for additional information

Region Specific Information

Head Trauma (Main) Neck Trauma Cardiac Trauma Pericardial Effusion Diaphragm Injury Abdominal Trauma Open Fracture Spinal Trauma (Main)

Workup

• ATLS/FAST/Trauma Labs
• CT Scan as needed depending on location
• X-ray if bony injury suspected
• CTA if vascular injury suspected

Management

• Trauma consult depending on location and extent of wound
• Ortho consult for bony injuries
• Neuro/OMF/ENT as needed

Disposition

• OR if significant injuries
• Admission/Obs for less concerning injuries
• Minor injuries may be discharged
• GSW Protocol allows lower extremity wounds to be discharged from ED after 9 hours without invasive imaging if they have normal ABIs