Gunshot Wounds in a Shell

About

Gun violence has become a violence epidemic throughout the world; there has been a whopping jump of 8% in incidences in the past 2 years, and as per data, nearly 500 people die every day all around the globe due to firearm injuries (including suicide).

But what are gunshot injuries?

Gunshot wounds are injuries that are caused by a bullet or any other projectile that can pierce into or through the body.

What Determines the Severity of the Injury?

These injuries can be severe and traumatic, and their severity depends on factors such as:

• Type of firearm used
• The distance from where the shot was fired
• The characteristics of the path of the bullet
• The location of the injury on the body

Gunshot injuries can cause both permanent and temporary injuries or cavities in the body that are along the path of the bullet that is fired from the gun.

Gunshot injuries can cause death due to various factors, including severe bleeding (hemorrhage), organ damage, and wound infection(1^✔).

Medico-Legal Importance of Gunshot Injuries

Gunshot wounds need to be examined by the fine eye of the forensic pathologist.

Step-by-Step Guide to Gunshot Wound Examination by a Forensic Pathologist

• Documentation of the wound characteristics
• Investigating the cause and manner of the injury
• Determining the entry and exit characteristics of the bullet
• Assessing the direction and distance of the shot

These details are critical in determining the manner of a gunshot injury and assist in the medico-legal aspect of the investigation(1^✔).

Types of Gunshot Wounds

Gunshot wounds can result in two types of wounds, depending on the direction of the pathway of the bullet.

Entry Wound:

An entry wound is a type of wound that occurs when a projectile, such as a bullet, enters the body. Entry wounds are generally smaller and more regular in shape than exit wounds.

Exit Wound:

An exit wound is a type of wound that occurs when a projectile exits the body after entering it. Exit wounds are generally larger and more irregular in shape than entry wounds.

Penetrating Wound:

The bullet enters the body and stays there, without exiting. This type of wound can cause significant damage to the internal organs and tissues.

Perforating Wound:

The bullet enters the body and exits from the other side. This type of wound can cause both entry and exit wounds, which may require different types of treatment.

Contact Wound:

The gun is pressed against the body when fired, causing burns and powder residue around the wound.

Grazing Wound:

The bullet strikes the skin but does not penetrate deeply, causing a superficial injury.

Fracture Wound:

The bullet shatters a bone in the body.

Cavity Wound:

The bullet creates a large temporary cavity within the tissue, causing damage to surrounding structures.

Characteristics of Gunshot Wounds

The nature of a wound can be determined by both the characteristics of the missile and the tissues it passes through.

The entry wounds are narrower and more uniform than exit wounds. Tissue penetration into the wound is seen in entry wounds, whereas outward beveling of tissue is seen in exit wounds(1^✔).

Mechanism of Gunshot Injuries

• When a bullet or other high-velocity projectile travels through the air, it creates a shockwave in front of it, creating pressure
• This pressure wave travels ahead of the bullet and can cause damage to tissues even before the bullet enters the body
• Once the bullet enters the tissue, the temporary cavity is created imparting energy to the tissue, causing it to move away from the path of the bullet which can contribute to the severity of the injury(2^✔).

Risk factors of Gunshot Wounds

Gunshot injuries are influenced by various factors, including the type of firearm used, the location of the incident, the intentions of the shooter, and the demographics of those involved.

Symptoms of Gunshot wounds

A gunshot wound can cause a range of symptoms depending on the severity and location of the injury.

• Pain
• Bleeding
• Shock
• Difficulty in breathing can occur if the gunshot wound is in the chest or abdomen
• Swelling and numbness or tingling sensation may also be present in case of nerve injury.

It's crucial to seek immediate medical attention for any gunshot wound, regardless of the severity of the symptoms. Delaying treatment can result in serious complications or even death.

Proper medical care can help prevent infection, control bleeding, and reduce the risk of long-term complications. Rehabilitation may also be necessary to regain full function of the affected area.

Diagnostic Procedure for Gunshot Wound

After sustaining a gunshot wound, patients who are considered to be stable and those who have been stabilized are evaluated through a thorough examination of their medical history and a physical examination.

As part of the evaluation process, a routine X-ray or CT scan can be performed(2^✔).

Treatment of Gunshot injury

Gunshot wounds require prompt and appropriate care to minimize the risk of complications and maximize the chances of a successful outcome.

Here are the steps to manage gunshot injuries:

• Assess the extent of the injury, including the location and depth of the wound and any associated injuries to nearby organs or tissues.
• Surgical intervention may be required
• Fasciotomy, a procedure to relieve pressure in the muscle fascia may be necessary
• A surgical revision of the abdominal cavity is necessary in cases of penetrating abdominal gunshot injuries.
• Wait and watch approach with surgical wound management and hospitalization. Infections of the gunshot wound are most common complications, so proper wound care is essential to minimize the risk of infection(3^✔).

Common Injuries from a Gunshot

Gunshot wound to head

Gunshot wounds that go through the skull but don't come out are called penetrating wounds, while wounds that enter and exit are called perforating wounds.

They can cause brain damage and even lead to death(4^✔).

Treatment of Gunshot Wound to Head

• Gunshot wound head trauma patients receive immediate resuscitation(life saving measures) upon arrival at the hospital
• CT scans of the head are taken
• Surgical treatment is considered based on various criteria
• Understanding the pathway of the bullet path is crucial in determining prognosis and management(4^✔).

Cardiac Injuries:

The heart is involved in approximately 15% of deep chest injuries. Cardiovascular injuries are the second most common cause of traumatic death after central nervous system injuries.

Extremities Injuries:

PTE(Penetrating trauma of Extremities)accounts for about 50% of penetrating trauma cases. Although there may be long-term complications, overall survival is generally high.

Head and Neck Injuries:

Penetrating injuries to the neck and face can be caused by the projectile (gun) and non projectile (knives and other sharp implements such as screwdrivers or glass) mechanisms.

Vessels Injuries:

MDCTA (Multidetector Computed Tomographic Angiography) is an accurate method to demonstrate vascular injuries associated with these wounds.

Medical Complications of Gunshot Wounds

• Pain is a common and long-lasting complication.
• Infections are a significant concern due to the introduction of foreign material and it may end up in shock.
• Pneumothorax(collection of air in the pleural cavity of lungs) can occur when a bullet penetrates the chest or back.
• Spinal fractures can be complex and difficult to treat and may also lead to injury to the spinal cord.
• Colonic perforation can occur if a bullet strikes the abdomen.
• Cerebrospinal fluid, which is present in the subarachnoid space of brain and spinal cord can leak result in a loss of fluid and an increased risk of infection.
• Retroperitoneal hematoma (collection of blood behind the peritoneum, which is the covering of abdominal cavity) can occur when a bullet strikes the abdomen, causing bleeding(5^✔).

Gunshot Wound Scar

Gunshot wound scar varies depending upon the site, extent and the type of firearm used. After a gunshot wound, the healing process involves inflammation, tissue repair, and remodeling. Initially, the scar is often red, swollen, and raised. Over the time, the scar can become pale and flatter, but it may vary depending upon individual.

Gunshot Wound Care and Recovery

Post Hospitalization Care

• Clean and dry the wound according to the instructions provided.
• Wash your hands before and after removing the old dressing, cleaning the wound, and applying the new dressing.
• Avoid using skin cleansers, alcohol, peroxide, iodine, or soaps with antibacterial chemicals on the wound unless instructed to do so by your provider.
• Don't use any lotion, cream, or herbal remedies on or around the wound without consulting your provider first.
• If you have non-dissolvable stitches or staples, your provider will remove them within 3 to 21 days. Don't try to remove them on your own(6^✔).

Rehabilitation and Therapy

Rehabilitation is an essential part of the recovery process for individuals who have sustained gunshot injuries.

The rehabilitation process involves a multidisciplinary approach and depending on the nature and severity of the injury, rehabilitation may include physical therapy, occupational therapy, speech therapy, and mental health counseling(7^✔).

Psychological Support

Sustaining a gunshot wound can be a traumatic experience that can cause various emotions such as shock, fear, depression, and anger.

If these symptoms continue, they may indicate the presence of post-traumatic stress disorder (PTSD), which can be treated effectively with appropriate care(6^✔).

Prevention of Gunshot Wounds

• Store the guns safely.
• Promoting education and awareness(8^✔).
• To prevent guns from being diverted to criminals, handgun licensing, background checks for all sales, and close supervision of gun sellers are effective(9^✔).

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