Gun shot wounds

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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[1]

Sources

  1. Sandjadi, Javid. Expedited treatment of lower extremity gunshot wounds.