Gunshot wound
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] Damage 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]
Gunshot wound
Guns
Illegal drug trade, ignorance of firearm safety, substance misuse, alcohol abuse, poor mental health, firearm laws, social and economic differences, some occupations, war[5][6]
1 million (interpersonal violence in 2015)[10]
251,000 (2016)[5]
Factors that determine rates of gun violence vary by country.[5] These factors may include the illegal drug trade, easy access to firearms, substance misuse including alcohol, mental health problems, firearm laws, social attitudes, economic differences, and occupations such as being a police officer.[5][6] Where guns are more common, altercations more often end in death.[13]
Before management begins, the area must be verified as safe.[9] This is followed by stopping major bleeding, then assessing and supporting the airway, breathing, and circulation.[9] Firearm laws, particularly background checks and permit to purchase, decrease the risk of death from firearms.[7] Safer firearm storage may decrease the risk of firearm-related deaths in children.[8]
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 $140 billion a year in the United States.[15]
Signs and symptoms[edit]
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.
The degree of tissue disruption caused by a projectile is related to the cavitation the projectile creates as it passes through tissue. A bullet with sufficient energy will have a cavitation effect in addition to the penetrating track injury. As the bullet passes through the tissue, initially crushing then lacerating, the space left forms a cavity; this is called the permanent cavity. Higher-velocity bullets create a pressure wave that forces the tissues away, creating not only a permanent cavity the size of the caliber of the bullet but a temporary cavity or secondary cavity, which is often many times larger than the bullet itself.[18] The temporary cavity is the radial stretching of tissue around the bullet's wound track, which momentarily leaves an empty space caused by high pressures surrounding the projectile that accelerate material away from its path.[17] The extent of cavitation, in turn, is related to the following characteristics of the projectile:
Diagnosis[edit]
Classification[edit]
Gunshot wounds are classified according to the speed of the projectile using the Gustilo open fracture classification:
Prevention[edit]
Medical organizations in the United States recommend a criminal background check being held before a person buys a gun and that a person who has convictions for crimes of violence should not be permitted to buy a gun.[14] Safe storage of firearms is recommended, as well as better mental health care and removal of guns from those at risk of suicide.[14] In an effort to prevent mass shootings, greater regulations on guns that can rapidly fire many bullets is recommended.[14]
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.[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]
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.[51]: M-9 Goodfellow pioneered the use of sterile techniques in treating gunshot wounds,[52] washing the person's wound and his hands with lye soap or whisky, and his patient, unlike the President, recovered.[53] He became America's leading authority on gunshot wounds[54] and is credited as the United States' first civilian trauma surgeon.[55]
Mid-nineteenth-century handguns such as the Colt revolvers used during the American Civil War had muzzle velocities of just 230– /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.[56]
Wilhelm Röntgen's discovery of X-rays in 1895 led to the use of radiographs to locate bullets in wounded soldiers.[57]
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.[57][58] Similar improvements were seen in US trauma practices during the Iraq War.[59] Military health care providers who return to civilian practice sometimes disseminate military trauma care practices.[57][60][61] 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 declines in the gun death rate in states that have stable rates of gunshot hospitalizations.[62][63][64][65]