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User:Omurphy5/Gunshot wound

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A gunshot wound (GSW) is physical trauma caused by a bullet from a firearm.[1][2] The severity of the trauma is determined by several factors, including the speed and type of the bullet and the area affected [2][3] Treatment for gunshot wounds can vary depending on the area of the body affected and which tissues have been damaged.[2] Short term damage can include damage to bones, organs, and muscle, while long term complications can include lead poisoning and post traumatic stress disorder (PTSD).[4][3][5]There are many factors that can increase the likelihood of an individual to be affected by gun related. Ongoing research with the goal of reducing the incidence and mortality of gunshot wounds is being conducted.[6]

Gunshot wound
Other namesGunshot injuries, ballistic trauma, bullet wound, firearm-related injuries
Male skull showing bullet exit wound on parietal bone, 1950s.
SymptomsPain, deformity, bleeding[7][8]
ComplicationsPTSD, lead poisoning, nerve injury[7][8][9]
Risk factorsIllegal drug trade, access to firearms, substance misuse including alcohol, mental health problems, firearm laws, social and economic differences[10][11]
PreventionFirearm laws, safer storage[12][13]
TreatmentTrauma care[14]
Frequency1 million (interpersonal violence in 2015)[15]
Deaths251,000 (2016)[10]

Diagnosis

[edit]

Symptoms

Gunshot wounds can be particularly devastating compared to other penetrating injuries because a bullet's movement can be unpredictable after entering the body[16]. The damage to body tissues is dependent on bullet velocity classification.[16]

The immediate effect of a gunshot wound is typically severe bleeding, and with it the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs, often due to extreme blood loss.[17] Devastating effects can result when a bullet strikes a vital organ such as the heart, lungs or liver, or damages a component of the central nervous system such as the spinal cord or brain.[17]

Classification

[edit]

Gunshot wounds are classified according to the speed of the projectile using the popular Gustilo Open Fracture Classification:

·       Low-velocity: Less than 1,100 ft/s (340 meters/second (m/s))

Low velocity wounds are typical of small caliber handguns and display wound patterns like Gustilo Anderson Type 1 or 2 wounds

·       Medium-velocity: Between 1,100 ft/s (340 m/s) and 2,000 ft/s (610 m/s)

These are more typical of shotgun blasts or higher caliber handguns like magnums. The risk of infection from these types of wounds can vary depending on the type and pattern of bullets fired as well as the distance from the firearm.

·       High-velocity: Between 2,000 ft/s (610 m/s) and 3,500 ft/s (1,100 m/s)

Usually caused by powerful assault or hunting rifles and usually display wound pattern similar to Gustilo Anderson Type 3 wounds. The risk of infection is especially high due to the large area of injury and destroyed tissue. [18]


Pathophysiology

The damaged caused to body tissue by a projectile relates to the cavitation the projectile creates as it passes through tissue. As the bullet passes through the tissue, it creates space in the tissue called the permanent cavity. Higher-velocity bullets create larger and additional secondary cavities.[19] The extent of cavitation, in turn, is related to the following characteristics of the projectile:

  • Kinetic energy: KE = 1/2mv2 (where m is mass and v is velocity). Larger, heavier bullets with a higher speed will produce a larger cavity than smaller, slower bullets. Although both mass and velocity contribute to the overall energy of the projectile, the velocity of the bullet has a greater impact on the overall energy. This is because when using the kinetic energy equation, if the mass of the bullet is doubled, the energy is doubled; however, if the velocity of the bullet is doubled, the energy increases four times.
  • Yaw: Higher velocity bullets may tumble as they pass through deep tissues, causing greater damage to the surrounding tissue.[19]
  • Bullet Type: Hollow-point bullets expand once they've penetrated body tissue, causing greater damage to surrounding tissue when compared to Full metal jacket bullets, which typically pass straight through a target [17]

Management

[edit]

Initial assessment for a gunshot wound is approached using the advanced trauma life support (ATLS) protocol.[20] These include:

Depending on the extent of injury, management can range from urgent surgical intervention to observation. As such, any history from the scene such as gun type, shots fired, shot direction and distance, blood loss on scene, and pre-hospital vitals signs can be very helpful in directing management. Unstable people with signs of bleeding that cannot be controlled during the initial evaluation require immediate surgical exploration in the operating room.[20] Otherwise, management protocols are generally dictated by entry point and anticipated trajectory.

Neck

[edit]
Penetrating neck injury protocol.[21]

A gunshot wound to the neck can be particularly dangerous because of the high number of vital structures contained within a small space. The neck contains important air passages, blood vessels, and nervous pathways. Gunshots to the neck can thus cause severe bleeding, airway compromise, and nervous system injury.[22]

Initial assessment of a gunshot wound to the neck involves non-probing inspection to avoid exacerbating the wound and determining whether the injury is a penetrating neck injury (PNI) or not, classified by violation of the platsyma muscle.[22] If the platsyma is intact, the wound is considered superficial and only requires local wound care. If the injury is a PNI, surgery should be consulted immediately.

Chest

[edit]

The chest houses many vital organs, including the lungs, heart, and major blood vessels. Gunshots to the chest can thus cause severe bleeding (hemothorax), respiratory compromise (pneumothorax, hemothorax, pulmonary contusion, tracheobronchial injury), cardiac injury (pericardial tamponade), and nervous system injury and often require immediate surgery.[23]

Non-serious wounds can be imaged using x-rays and examined periodically to ensure no further damage occurs.


Abdomen

[edit]
Abdominal gunshot wound

The abdomen contains organs vital to digestion, excretion, and circulation including the stomach, kidneys, liver and spleen. Initial evaluation of a gunshot wound to the abdomen should determine if there is uncontrolled bleeding, inflammation of the peritoneum, or spillage of bowel contents. These all require immediate surgical intervention.[24]

Due to the difficulty in accessing areas within the abdomen, imaging is done to determine the extent of injury.[25] Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectory and fragmentation.[25] However, the best and preferred mode of imaging is high-resolution multi-detector CT (MDCT) with IV, oral, and sometimes rectal contrast.[25] Severity of injury found on imaging will determine whether the surgeon takes an operative or close observational approach.


Extremities

[edit]
Acute penetrating trauma from a close-range shotgun blast injury to knee. Birdshot pellets are visible in the wound, within the shattered patella. The powder wad from the shotgun shell has been extracted from the wound, and is visible at the upper right of the image.

The four main components of extremities are bones, vessels, nerves, and soft tissues. Gunshot wounds can thus cause severe bleeding, fractures, nerve deficits, and soft tissue damage. The Mangled Extremity Severity Score (MESS) is used to classify the severity of injury.[26] Depending on the extent of injury, management can range from superficial wound care to limb amputation. [26]

As with other traumatic cases, those with uncontrolled bleeding require immediate surgical intervention.[20] If surgical intervention is not readily available and direct pressure is insufficient to control bleeding, tourniquets or direct clamping of visible vessels may be used temporarily to slow active bleeding.[27]

Once the bleeding has been stopped and the patient is evaluated for further signs of vascular damage, if the damage to an extremity is severe enough according to the MESS, limb amputation may be considered [26].

Long Term Effects

[edit]

The majority of gunshot related surgeries and costs result from long-term treatment for gunshot wounds[28]. Patients with wounds to the upper body were more likely to seek continued treatment[28].

Although somewhat rare, The Johns Hopkins Bloomberg Center for Public Health has shown that bullets can cause lead poisoning [29]. Lead poisoning is more likely to occur when bullets are left in joints or pseudo-cysts[29]. This is due to the presence of synovial fluid in these areas, which allows lead from the bullet to dissolve and enter the bloodstream[29]. This soluble form of the lead then precipitates in the bloodstream and is absorbed by macrophages, which later deposited in the blood, soft tissue such as the liver and kidneys, as well as the bone marrow. The lead then causes inflammation and interrupts cellular metabolism as is characteristic of lead poisoning.[30]

Studies show that survivors of gunshot wounds are also more likely to suffer from Post Traumatic Stress Disorder and displayed an increased chance of abusing substances such as drugs and alcohol [31] [32][33]. Since shootings are often not predicted, survivors may struggle to feel safe and unable to protect themselves in the future. Some of the PTSD symptoms they may experience include frequent nightmares, avoidance of situations that remind them of the situation, anxiety and fear, being constantly on guard and sleeplessness [29][33].

History

[edit]

Until the 1880s, the standard practice for treating a gunshot wound called for physicians to insert their unsterilized fingers into the wound to probe and locate the path of the bullet.[34] Standard surgical theory such as opening abdominal cavities to repair gunshot wounds,[35] germ theory, and Joseph Lister's technique for antiseptic surgery using diluted carbolic acid, had not yet been accepted as standard practice. For example, sixteen doctors attended to President James A. Garfield after he was shot in 1881, and most probed the wound with their fingers or dirty instruments.[36] Historians agree that massive infection was a significant factor in Garfield's death.[34][37]

At almost the same time, in Tombstone, Arizona Territory, on 13 July 1881, George E. Goodfellow performed the first laparotomy to treat an abdominal gunshot wound.[38]: M-9  Goodfellow pioneered the use of sterile techniques in treating gunshot wounds,[39] washing the person's wound and his hands with lye soap or whisky.[40] He became America's leading authority on gunshot wounds[41] and is credited as the United States' first civilian trauma surgeon.[42]

Mid-nineteenth-century handguns such as the Colt revolvers used during the American Civil War had muzzle velocities of just 230–260 m/s and their powder and ball predecessors had velocities of 167 m/s or less. Unlike today's high-velocity bullets, nineteenth-century balls produced almost little or no cavitation and, being slower moving, they were liable to lodge in unusual locations at odds with their trajectory.[43]

Wilhelm Röntgen's discovery of X-rays in 1895 led to the use of radiographs to locate bullets in wounded soldiers.[44]

Survival rates for gunshot wounds improved among US military personnel during the Korean and Vietnam Wars, due in part to helicopter evacuation, along with improvements in resuscitation and battlefield medicine.[44][45] Similar improvements were seen in US trauma practices during the Iraq War.[46] Some military trauma care practices are disseminated by citizen soldiers who return to civilian practice.[44][47][48] One such practice is to transfer major trauma cases to an operating theater as soon as possible, to stop internal bleeding. Within the United States, the survival rate for gunshot wounds has increased, leading to apparent declines in the gun death rate in states that have stable rates of gunshot hospitalizations.[49][50][51][52]


Epidemiology

[edit]
Further information: List of countries by firearm-related death rate

In 2015 about a million gunshot wounds occurred from interpersonal violence. Firearms, globally in 2016, resulted in 251,000 deaths up from 209,000 in 1990.[10] Of these deaths 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 were accidents.[10] Firearm related deaths are most common in males between the ages of 20 to 24 years.[10]

The countries with the greatest number of deaths from firearms are Brazil, the United States, Mexico, Colombia, Venezuela, and Guatemala which make up just over half the total [10]. As of 2016, the countries with the highest rates of gun violence per capita were El Salvador, Venezuela, and Guatemala with 40.3, 34.8, and 26.8 violent gun deaths per 100,000 people respectively [53]. The countries with the lowest rates of were Singapore, Japan, and South Korea with 0.03, 0.04, and 0.05 violent gun deaths per 100,000 people respectively[53].

Figures from the Johns Hopkins Bloomberg Center for Public Health show that regions in South and Central America as well as Sub-Saharan Africa suffered from high levels of gunshot related deaths relative to the population size [54]. The data showed that increased gun ownership correlates positively with suicide rates and gun violence [54]. Behaviors that also contributed to increased gun violence were an increase in drug and alcohol abuse as well as unsafe gun carrying and storage policies[54]. When analyzing gunshot wound data and gun violence data, underlying social behaviors and trends may be to blame for gun violence, such as depression and Post Traumatic Stress Disorder [54]. A clinical study showed that intervention that targets these behaviors among youth and adolescents showed a significant reduction in the amount of gunshot injuries treated in trauma centers, suggesting that addressing these behaviors could lower the amount of gunshot wounds and gunshot violence[54].

The Johns Hopkins Bloomberg Center for Public Health found a few factors that may increase an individuals risk for being a victim of a gunshot wound or gunshot related trauma. These include having early exposure to violence, both domestic and gang-related, or being involved in violent and abusive relationships[54]. Areas with fewer background checks and less comprehensive gun laws were also found to have higher incidences of homicides from gunshot wounds[54].

United States

[edit]
Further information: Gun violence in the United States

In 2017 there were 39,773 deaths in the United States as a result gunshot wounds.[55] Of these 60% were suicides, 37% were homicides, 1.4% were by law enforcement, 1.2% were accidents, and 0.9% were from an unknown cause.[55] This is up from 37,200 deaths in 2016 due to a gunshot wound (10.6 per 100,000).[10] With respect to those that pertain to interpersonal violence, it had the 31st highest rate in the world with 3.85 deaths per 100,000 people in 2016.[53] The majority of all homicides and suicides are firearm-related, and the majority of firearm-related deaths are the result of murder and suicide.[56] Firearms account for nearly 80% of all fatal suicide attempts [57].

The Unites States is an anomaly, being the only Western democracy with a high rate of gunshot wound victims per capita [54]. When sorted by GDP, the United States has a much higher violent gun death rate compared to other developed countries, with over 10 times the number of firearms assault deaths than the next four highest GDP countries combined.[58]

A study from the Johns Hopkins University School of Medicine found that hospitalization and treatment for gunshot wounds costs the United States approximately 2.8 billion dollars annually[59]. The percentage of patients who suffered from mental health disorders as well as victims of unintentional gunshot wounds increased during the time the study was conducted [59]. The Johns Hopkins Hospital also found that gunshot wounds on average are the most expensive type of trauma-related injury to treat and have the highest rate of mortality among trauma patients [60].

Prevention

[edit]

Research from the Johns Hopkins Center for Gun Policy and Control has found some of the most common and effective strategies for preventing gunshot wounds and gun related trauma:

  • Background Checks: These prevent individuals who may pose a threat to others by purchasing illegal firearms and potentially inflicting gunshot wounds upon other individuals[61][62]. Background checks were found to reduce the amount of illegal gun purchases by these individuals in states that had comprehensive background check laws[61].
  • Suicide Prevention: 60 percent of gun-related deaths are a result of suicide, and gun policy designed to prevent at-risk individuals from obtaining firearms has been found to be effective[63]. Methods include background checks performed online and in person as well as issuing gun violence restraining orders to individuals with histories of gun violence[64][65]. Over the long-term, figures from the Johns Hopkins Bloomberg School of Health reported a decrease in suicides from gunshot wounds when comprehensive policy was enacted [66].
  • Proper Gun Storage: Mishandling of firearms is a cause of gunshot wounds[67]. Proper safe storage of firearms is key to reducing access of firearms to unauthorized or at risk individuals [64][68]. Children are often victims of unintentional gunshot wounds from improper storage, and proper firearm storage laws have been found to reduce the frequency of these types of gunshot wounds[68].
  • Education: The Center provides many different programs to raise awareness about gunshot wounds and gun related violence. Programs include a free, large online course called "Reducing Gun Violence in America: Evidence for Change" which helps learners understand pertinent gun policy and the issues surrounding these policies as well as popular and effective tools for intervention[69]. There is also a similar program offered by the center which targets a youth audience to educate them about gun related trauma prevention as well as leadership and advocacy for the prevention of gun violence and gunshot wounds[69].


See also

[edit]
  • Stab wound, an equivalent penetrating injury caused by a bladed weapon or any other sharp objects.
  • Blast injury, an injury that may present similar dangers to a gunshot wound.

References

[edit]
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