A gunshot wound (GSW) is a penetrating injury caused by a projectile (e.g. a bullet) from a gun (typically firearm or air gun).[11][12] Damages may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death.[2] Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet.[12] Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.[1][2]
In 2015, about a million gunshot wounds occurred from interpersonal violence.[10] In 2016, firearms resulted in 251,000 deaths globally, up from 209,000 in 1990.[5] Of these deaths, 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 (9%) were accidents.[5] In the United States, guns resulted in about 40,000 deaths in 2017.[14] Firearm-related deaths are most common in males between the ages of 20 and 24 years.[5] Economic costs due to gunshot wounds have been estimated at US$140 billion a year in the United States.[15]
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Trauma from a gunshot wound varies widely based on the bullet, velocity, mass, entry point, trajectory, affected anatomy, and exit point. Gunshot wounds can be particularly devastating compared to other penetrating injuries because the trajectory and fragmentation of bullets can be unpredictable after entry. Moreover, gunshot wounds typically involve a large degree of nearby tissue disruption and destruction caused by the physical effects of the projectile correlated with the bullet velocity classification.[16]
The immediate damaging effect of a gunshot wound is typically severe bleeding with the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs.[17] In the case of traumatic hypovolemic shock, this failure of adequate oxygen delivery is due to blood loss, as blood is the means of delivering oxygen to the body's constituent parts. 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]
Common causes of death following gunshot injury include bleeding, low oxygen caused by pneumothorax, catastrophic injury to the heart and major blood vessels, and damage to the brain or central nervous system. Non-fatal gunshot wounds frequently have mild to severe long-lasting effects, typically some form of major disfigurement such as amputation because of a severe bone fracture and may cause permanent disability. A sudden blood gush may take effect immediately from a gunshot wound if a bullet directly damages larger blood vessels, especially arteries.
A gunshot wound to the neck can be particularly dangerous because of the high number of vital anatomical structures contained within a small space. The neck contains the larynx, trachea, pharynx, esophagus, vasculature (carotid, subclavian, and vertebral arteries; jugular, brachiocephalic, and vertebral veins; thyroid vessels), and nervous system anatomy (spinal cord, cranial nerves, peripheral nerves, sympathetic chain, brachial plexus). Gunshots to the neck can thus cause severe bleeding, airway compromise, and nervous system injury.[26]
Initial assessment of a gunshot wound to the neck involves non-probing inspection of whether the injury is a penetrating neck injury (PNI), classified by violation of the platysma muscle.[26] If the platysma is intact, the wound is considered superficial and only requires local wound care. If the injury is a PNI, surgery should be consulted immediately while the case is being managed. Of note, wounds should not be explored on the field or in the emergency department given the risk of exacerbating the wound.
Due to the advances in diagnostic imaging, management of PNI has been shifting from a "zone-based" approach, which uses anatomical site of injury to guide decisions, to a "no-zone" approach which uses a symptom-based algorithm.[27] The no-zone approach uses a hard signs and imaging system to guide next steps. Hard signs include airway compromise, unresponsive shock, diminished pulses, uncontrolled bleeding, expanding hematoma, bruits/thrill, air bubbling from wound or extensive subcutaneous air, stridor/hoarseness, neurological deficits.[27] If any hard signs are present, immediate surgical exploration and repair is pursued alongside airway and bleeding control. If there are no hard signs, the person receives a multi-detector CT angiography for better diagnosis. A directed angiography or endoscopy may be warranted in a high-risk trajectory for the gunshot. A positive finding on CT leads to operative exploration. If negative, the person may be observed with local wound care.[27]
Initial workup as outlined in the Workup section is particularly important with gunshot wounds to the chest because of the high risk for direct injury to the lungs, heart, and major vessels. Important notes for the initial workup specific for chest injuries are as follows. In people with pericardial tamponade or tension pneumothorax, the chest should be evacuated or decompressed if possible prior to attempting tracheal intubation because the positive pressure ventilation can cause hypotention or cardiovascular collapse.[29] Those with signs of a tension pneumothorax (asymmetric breathing, unstable blood flow, respiratory distress) should immediately receive a chest tube (> French 36) or needle decompression if chest tube placement is delayed.[29] FAST exam should include extended views into the chest to evaluate for hemopericardium, pneumothorax, hemothorax, and peritoneal fluid.[29]
However, not all gunshot to the chest require surgery. Asymptomatic people with a normal chest X-ray can be observed with a repeat exam and imaging after 6 hours to ensure no delayed development of pneumothorax or hemothorax.[29] If a person only has a pneumothorax or hemothorax, a chest tube is usually sufficient for management unless there is large volume bleeding or persistent air leak as noted above.[29] Additional imaging after initial chest X-ray and ultrasound can be useful in guiding next steps for stable people. Common imaging modalities include chest CT, formal echocardiography, angiography, esophagoscopy, esophagography, and bronchoscopy depending on the signs and symptoms.[33]
The most important initial evaluation of a gunshot wound to the abdomen is whether there is uncontrolled bleeding, inflammation of the peritoneum, or spillage of bowel contents. If any of these are present, the person should be transferred immediately to the operating room for laparotomy.[34] If it is difficult to evaluate for those indications because the person is unresponsive or incomprehensible, it is up to the surgeon's discretion whether to pursue laparotomy, exploratory laparoscopy, or alternative investigative tools.
Although all people with abdominal gunshot wounds were taken to the operating room in the past, practice has shifted in recent years with the advances in imaging to non-operative approaches in more stable people.[35] If the person's vital signs are stable without indication for immediate surgery, imaging is done to determine the extent of injury.[35] Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectory and fragmentation.[35] However, the best and preferred mode of imaging is high-resolution multi-detector CT (MDCT) with IV, oral, and sometimes rectal contrast.[35] Severity of injury found on imaging will determine whether the surgeon takes an operative or close observational approach.
In 2015, about a million gunshot wounds occurred from interpersonal violence.[10] Firearms, globally in 2016, resulted in 251,000 deaths up from 209,000 in 1990.[5] Of these deaths 161,000 (64%) were the result of assault, 67,500 (27%) were the result of suicide, and 23,000 were accidents.[5] Firearm related deaths are most common in males between the ages of 20 to 24 years.[5]
In 2017, there were 39,773 deaths in the United States as a result gunshot wounds.[14] 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.[14] This is up from 37,200 deaths in 2016 due to a gunshot wound (10.6 per 100,000).[5] 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.[42] The majority of all homicides and suicides are firearm-related, and the majority of firearm-related deaths are the result of murder and suicide.[44] When sorted by GDP, however, 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.[45] Gunshot violence is the third most costly cause of injury and the fourth most expensive form of hospitalization in the United States.[46]
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.[47] Standard surgical theory such as opening abdominal cavities to repair gunshot wounds,[48] 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.[49] Historians agree that massive infection was a significant factor in Garfield's death.[47][50] ff782bc1db
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