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CE/Gunshot Wounds: A Primer

CE/Gunshot Wounds: A Primer

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05/11/2014

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CE/Gunshot Wounds: A Primer
Glenn G. Williams, MDEmergency Medicine ResidentCarl W. Gossett, MD, FACEPAssistant ProfessorDepartment of Emergency MedicineScott & White Clinic and Memorial HospitalScott, Sherwood and Brindley FoundationTexas A&M University Health Science CenterCollege of MedicineTemple, Texas
Objectives
After reading this article, you will be able to describe the:1.Appearance of multiple types of gunshot wounds.2.Patient evaluation of gunshot wounds.3.Apropriate treatment of gunshot wounds
Case
9-1-1 receives a call from the owner of a liquor store near the county line who has just been shot in theface by a robber. The man is alert and coherent with slurred speech. He is requesting immediateassistance from police and ambulance. He warns dispatchers that he anticipates the return of the thiefbecause, in his haste to escape with the cash, the perpetrator forgot his wallet. Shortly thereafter, the 9-1-1 operator hears shouting and two distinct sets of gunshots.
Introduction
Firearms and gunshot wounds are now common in today’s society. Hot debate continues to rageregarding cause, effect and the best way to handle the ever- increasing number of deaths resulting fromguns. Emergency services must also examine their response to such an environment. This articleprovides a brief overview of current information on the subject.
Before You Arrive
Prior to arriving on the scene of a shooting, assess the situation. Security is paramount. Has lawenforcement secured and stabilized the scene? Are all the combatants and weapons accounted for? Isthe firefight ongoing? Just what are you about to walk into—a family dispute, robbery, gangland styledrive-by? Timely information from dispatch may assist you in making such an assessment; however,such information may be unavailable or inaccurate. Approach every scene as if your life depended uponit. Seek site information from law enforcement. Know the area, alternate routes in and out, have optionsfor escape available and stay mobile. Approach the scene with your windows rolled down. You may beable to assess the scene from conversations, voice intonations, and sounds (like the distinctive sound of
 
a pump shotgun being cycled). If trouble is still brewing, back off. Ambulances make great targets andyou will not be able to assist the patient if you get shot or pinned down.
Body Armor
is another consideration. Unfortunately, they have to be worn to provide any protection.Too often vests are left sitting behind the seat in the unit, instead of being placed on the paramedic whenneeded. While most EMS services are probably not issuing armor to their medics, an increasing numberare. Up to 37% of body surface area, to include most of the vital organs, can be protected from mosthandgun and shotgun projectiles with a vest. Rifle projectiles, on the other hand, are a different story.They have a higher velocity and are more difficult to protect against.
EVALUATION 
History
A knowledge of firearms, ballistics, and a simple reconstruction of the shooting will help you properlyassess the victim’s potential injuries. Ask other emergency response personnel, family members, thevictim, or witnesses what kind of weapon was used (handgun, rifle, or shotgun), the size of the weapon(the caliber is usually printed on the bottom of empty shell casings), type of bullet used, and distancefrom which the patient was shot. It is also helpful to ask how many shots were heard.
Physical Examination
General Appearance: Is the patient armed? It is imperative that you remove any threat to you, thepatient, and bystanders. Look for a weapon. Turn the weapon over to the nearest law enforcementpersonnel. If no one is available, remove the weapon, engage the safety, and unload the remainingrounds, but only if you know how.
ABCs
Airway: Secure the airway while taking precautions to stabilize the cervice spine, if indicated.Breathing: If the patient is not breathing, begin ventilation using bag-valve-mask while preparing tointubate. Hyperventilate patients with head wounds. If the patient has adequate spontaneousrespirations, supply 100% O2 from a non-rebreather. Be sure to check for adequate and bilateral chestexpansion and breath sounds.Circulation: Determine pulse rate and blood pressure. While there is some controversy about the propertreatment for traumatic injuries resulting in hypotension, aggressive fluid resuscitation with normal salineor lactated Ringer’s solution through two large bore IVs (14 -16 gauge) is still the standard of care.Control hemorrhage with direct pressure or application of PASG, if not contraindicated. As with alltreatment, be sure to consult your local protocols.Neurological Deficits: Because the bullet path may not be easily determined without direct visualization,the assumption of possible neurologic involvement must be made. Assess the patient’s level ofconsciousness, pupillary reflex, response to verbal and pain stimuli, as well as movement and sensationin the extremities.Examination: Remove all clothing and perform a head-to-toe examination while looking for additinoalentry or exit wounds and any other unseen injuries.
Entrance and Exit Wounds
Usually, it is easy to distinguish a shotgun wound at close range — a large, devastating entrance woundwith no exit wound. The entrance and exit wounds from a rifle or handgun are often more difficult toidentify.
 
The elastic properties of the skin and surrounding tissue as well as the small diameter of thesingle projectile make measurement misleading.
 
Range also plays a part in identifying entrance wounds. Close proximity shots will have gunpowderstippling or tattooing. In contact wounds, the hot gases accompanying the projectile create a largerentrance wound than expected for that caliber and carry any material the muzzle was in contact withdeep into the wound.Exit wounds, on the other hand, are generally larger and may contain debris such as bone, solid organparticles and projectile fragments. They can be distinguished approximately 60% of the time from theentrance wound.Never assume a patient was hit by only one bullet.There may be more than one exit wound. Depending on bullet fragmentation, bone or other fragmentssuch as pocket contents may have been blown through the wound creating multiple exit tracts.
Head
Examine the scalp for entrance and exit wounds.
Look for blood, fluid or vomitus in the ears and mouth. Observe for postauricular ecchymosis (Battlesign) and periorbital ecchymosis (“raccoon eyes”) which may indicating a basal skull fracture.
Wounds to the head, face, mouth or neck suggest cervical spine injury.
Airway compromise from maxillofacial injuries is potentially lethal due to hemorrhage, swelling anddebris. Immediate stabilization of the airway is imperative.
Airway patency should be reevaluated throughout transport.
Neck
Distended neck veins may result from a tension pneumothorax or cardiac tamponade.
Tracheal deviation may indicate tension pneumothorax or soft tissue swelling from a bullet.
Crumpling cellophane sensation under the skin of the neck may indicate a pneumothorax withsubcutaneous emphysema.
Neck wounds require aggressive airway management due to the potential for rapid deterioration.Intubation should be attempted immediately in an unconscious patient.
Torso
Trunk wounds may consist of penetrations either to the chest or abdominal cavity.
Bullet paths are seldom linear and no assumptions can be made as to the organs damaged. Observefor pneumothorax, hemothorax, cardiac tamponade, visceral or solid organ damage.
Don’t forget to check the axillae or perineum for entrance and exit wounds.
Internal injuries often present with a tender or rigid abdomen.
Extremities
Evaluate extremities for any deformities, tenderness, pallor, cyanosis or pulselessness.

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