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Hello there. I recently pulled out an old essay that I wrote about 7 years ago, and I'm hoping someone here might have additional points that they'd care to talk about? Please forgive the immaturity of the writing and referencing, it was written in my second semester of Community College, in my first English class. I've since learned proper citation 😎 In all it's infancy, the paper still contains some good information and I'd be very interested in hearing any other comments related to the topic.
Firearm damage presents very complex and special problems in emergency care. Expert recognition is vital in realizing difference between superficial entrance wounds and any internal injuries which may have occurred. Actions to be taken consist not only of precautions regarding infection and shock, but also those pertaining to the area of penetration within the body.
Extent of wounding from gunshot largely depends on the type and caliber of weapon used, as well as type of ammunition. High-powered rifles can generate energy 60 times greater than that of handguns. Distance from the weapon to the injured person mass and velocity of the ammunition, region of the body and organs injured are all determining factors in the damage incurred. Ballistics is a key factor in extent of damage. Bullets can produce direct and indirect tissue damage in three ways:
1. Crushing
2. Cavitation: causing a permanent cavity, and
3. Shock waves: representing the bullet's sound striking the surface of an object, in this case, the body's vital organs. These shock waves can compress tissue and travel ahead of the bullet (Cooper 38).
Secondary damage can also occur from fragments of a fractured bullet or from a high-energy bone impact. If the injury involves high-energy femoral fracture, abdominal injury may occur. Organs close to the bullet trajectory may be damaged by pressure waves, this second damage being frequent in high-energy injury. Bullets also have the capacity for high-speed bounce throughout the body, creating a potential path of destruction. The various 'tumbling' possibilities are yaw, precession and nutation (Ferrera 612).
According to studies done by Janzon and Seeman, there are four distinct measurements for analyzing tissue damage and destruction. They are:
1. Damage by direct contact with, and static disruption of, tissue.
2. Damage caused by high overpressures in the immediate vicinity of a projectile, penetrating at a high velocity. These pressures are caused by the flow of tissue around the projectile, cause a contusion-and-concussion-type injury.
3. Damage caused by expansion of a temporary cavity, reaching its maximum dimensions long after (milliseconds) the passage of the bullet. The injury is by tear damage, caused by stretching beyond the elastic limit of the tissues, and
4. Damage caused by the collapse of the temporary cavity. This injury could be of a contusion/concussion type caused by the pressure being brought about by the violent collapse of the cavity (implosion). It could also be of a tear/disruption type, caused by instabilities of the interior cavity surface during collapse (Cooper 39).
Senior EMS Paramedic, *edited*, states the first and foremost considerations for the primary caregiver are always the ABC's, airway, breathing and circulation. Then, oxygen and immediate transport. It's also important to learn the trajectory path of the bullet, which you can observe upon finding the exit wound of the bullet, if there is one. Learning of the type of gun involved and the ammunition can serve greatly in helping the doctors in surgery." Emergency Medicine Physician, *edited*, states that, "All gunshot trauma cases are regarded as life-threatening injury until proven otherwise. Regardless of mechanism of injury, in any seriously penetrating gunshot wound, you must assume that the surrounding organs are in jeopardy. The work of the primary caregiver is incredibly crucial from the moment they arrive on the scene. Avoiding aspiration should be one of the strongest primary considerations."
Primary consideration would also be given to possibility of cardiovascular shock. "Therapy must proceed quickly before extensive damage to vital organs can occur" (Dambro 978). Direct pressure on the wound is extremely important in the beginning stages of blood loss. Loss of blood from the said penetrating wound, whether an exit wound is present or not, can result in "inadequate perfusion (oxygen supply) of tissues, which results in organ dysfunction, cellular and organ damage, and, if not corrected quickly, death of the patient" (Dambro 378). This type of shock can manifest itself in different contexts in relation to the type of injury sustained. For example, hypovolemic shock refers to severe reduction of cardiac output due to loss of intravascular volume, most often caused by mostly external blood loss resulting in reduced venous return to the heart. In comparison, distributive shock would be in reference to the maldistribution of blood throughout the body, perhaps from the rendering of a major artery (Dambro 978).
Tests can be given to determine which type of shock has been sustained, including endoscopy/radioisotope bleeding scans. CAT scans, echocardiograms (which may detect and/or quantify pericardial effusions due to pericardial tamponade), lung scans and/or pulmonary arteriography for the detection of vascular injury (including massive pulmonary embolism, as well as pulmonary artery (Swan-Ganz) catheterization for serial measurement of cardiac output, central venous, pulmonary arterial and pulmonary arterial occlusion pressures, and vascular resistance (Dambro 978).
In regards to surgical procedure, each area of the body obviously adheres to specific procedure and technique. Specific regions include the head, thorax, pulmonary, cardiovascular, gastrointestinal, abdominal and extremities. Surgical treatment of wounds to the head involves extreme caution due to risk of imposing further neurological damage. Caution must be given in regards to bone fragments, which may have positioned within the brain.
The neck region contains representations of almost every vital structure, including respiratory, vascular, digestive, endocrine, and neurologic. Heavy blood loss can occur through injuries to the neck region from the carotid artery. The spinal area can also include many serious associated complications, most related to neurologic deterioration and respiratory failure, the latter having a 21% mortality rate (Mattox 464).
Debridement (laying open the wound, as well as removing all non-viable tissue) and excision of all foreign objects and contaminants, especially organic matter, is intitially necessary. Finding the distinguishing line between viable and non-viable tissue can be done using the 'four C's'. These are:
1. Color: a dark-red appearance indicating a lack of oxyhaemoglobin in the tissue, due to poor or absent circulation.
2. Contractility: healthy muscle contracts when touched or pinched.
3. Consistency: a mushy appearance indicating damaged tissue, and
4. Capillary bleeding: when cut, blood from capillaries seeps out into healthy muscle.
Also to be considered is the possibility of deep infections such as traumatic gas gangrene, a form of Clostridial infection that encompasses a possible cause of over 60 gram-positive anaerobic spore-forming rods. This condition results from gas that is produced by the bacteria becoming present in tissue, developing first and most commonly after deep, penetrating and/or crush injury that comprises the blood supply (e.g. gunshot wound). It's incubation period is less than 24 hours but ranges from 6 to 8 hours to several days. Gas present in tissue (as in crepitance) may be obvious in physical examination, soft tissue radiographs, or CT. Associated signs of systemic toxicity develop rapidly, including tachycardia, fever and diaphoresis, followed by shock and multi-organ failure. Bacteremia occurs in 15% of patients and can be associated with brisk hemolysis (the liberation of hemoglobin from red blood cells, brought about by a certain substance acting in conjunction with complement of clotting factor, causing the dissolution of red blood cells and disseminated intravascular coagulation). Complication can include jaundice, hemorrhage, renal failure, hypotension and liver necrosis (Bennett 1631).
Diagnosis of Clostridial Gas Gangrene consists of recognizing pain at the site of prior injury, together with signs of systemic toxicity and gas in the tissue. Definitive diagnosis depends on discovery of large gram-positive rods at the injury site or in the blood. Surgical exploration is essential and demonstrates muscle that does not bleed or contract when stimulated, though in some cases bleeding is a good sign of circulation. Some surgeons will 'nick' the muscle to check for blood flow. Muscle tissue may be edematous and have reddish blue to black discoloration. Treatment includes the administering of penicillin, clindamycin, tetracycline, chloramphenicol, metronidazole, or a number of cephalosporins that have excellent in vitro activity against Clostridia. Aggressive surgical debridement is mandatory to improve survival and prevent further complications. The use of hyperbaric oxygen (HBO) has presented equivocal results when combined with antibiotics and surgical debridement (Bennett 1632).
Patients with a diagnosis of gas gangrene of an extremity have a better prognosis than those with truncal or intra-abdominal gas gangrene, largely because it is difficult to operate on such lesions. It is to be noted that surgical closure of traumatic wounds should be avoided. Antibiotic treatment of such contaminated wounds is extremely necessary and vital. Gas gangrene can also occur in the heart and brain, as well as in the extremities. Other possible deep infections with muscle involvement include streptococcal myositis (muscular discomfort or pain resulting from infection or unknown cause), anaerobic myonecrosis, hemolytic streptococcal infection, acute and infectious staphylococcal anaerobic cellulitis, crepitant phelgmon, and Fournier's gangrene. Aspiration and dissemination of air into wounds by muscular activity and subcutaneous emphysema related to air-leak syndrome or trauma are of concern (Dambro 38).
A survey taken in 1996 by Arthur L. Kellerman, from the New England Journal of Medicine, shows that out of 86 firearm-related injuries, 30% of those were injured in the leg area, 18% were shot in the hands or fingers, and 10% were shot in the feet or toes. Firearm-related injuries sustained in the head, face, neck, chest and abdomen accounted for a combined 23%. The primary type of firearm used was a handgun, with riles and shotguns following far behind, each having a percentage of about 4%. This study was taken from 3 different cities, Memphis, Seattle, and Galveston, and was based on different race/ethnic groups, with most of the incidents occurring within the victim's own homes by the victims themselves.
Anatomical and physiological gunshot trauma can be an immensely complex and intricate condition with possibility of extreme consequence, and should in no way be regarded lightly. Expert medical care is most often required for survival. Survival depends not only on the extremity of the wound, but also as importantly on the care given by EMS first response and the ER/OR constitution of care received thereafter.
References
Bennet and Plum, ed. Cecil Textbook of Medicine. 20th edition. New York: Norton, 1999
Cooper J. Grahama, OBE, PhD, Dudley, Hugh A.F., CBE, MCh, FRCS, Gann, Donald S. MD, Little, Roderick A., PhD, FRCPath, FFAEM, Maynard, Robert L., BSc, MB, BCh, MRCPath, MRCP, ed. Scientific Foundations of Trama. Great Britain: Butterworth-Henemann 1997
Dambro, Mark R, MD, ed. Griffith's 5 Minute Clinical Consult. 9th ed. Philadelphia: Lippincott Williams and Wilkins, 2001.
Ferrera, Peter C. M.D., Colucciello, Stephen A., M.D., Marx, John A., M.D., Verdile, Vincent P., M.D., Gibbs, Michael A., M.D., ed. Trauma Management-An Emergency Medicine Approach. St Louis: Mosby, 2001.
Ferro, Jeffrery. Gun Control: Restricting Rights or Protecting People? (Information Series on Current Topics). New York: Mass Market, 1997.
Kellerman, Arthur L. et al. "Injuries due to Firearms in Three Cities." New England Journal of Medicine, vol.335, no.19. November 7, 1996.
Mattox, Kenneth L., Feliciano, David V., Moore, Ernst E., ed. Trauma. International: McGraw-Hill 2000.
Firearm damage presents very complex and special problems in emergency care. Expert recognition is vital in realizing difference between superficial entrance wounds and any internal injuries which may have occurred. Actions to be taken consist not only of precautions regarding infection and shock, but also those pertaining to the area of penetration within the body.
Extent of wounding from gunshot largely depends on the type and caliber of weapon used, as well as type of ammunition. High-powered rifles can generate energy 60 times greater than that of handguns. Distance from the weapon to the injured person mass and velocity of the ammunition, region of the body and organs injured are all determining factors in the damage incurred. Ballistics is a key factor in extent of damage. Bullets can produce direct and indirect tissue damage in three ways:
1. Crushing
2. Cavitation: causing a permanent cavity, and
3. Shock waves: representing the bullet's sound striking the surface of an object, in this case, the body's vital organs. These shock waves can compress tissue and travel ahead of the bullet (Cooper 38).
Secondary damage can also occur from fragments of a fractured bullet or from a high-energy bone impact. If the injury involves high-energy femoral fracture, abdominal injury may occur. Organs close to the bullet trajectory may be damaged by pressure waves, this second damage being frequent in high-energy injury. Bullets also have the capacity for high-speed bounce throughout the body, creating a potential path of destruction. The various 'tumbling' possibilities are yaw, precession and nutation (Ferrera 612).
According to studies done by Janzon and Seeman, there are four distinct measurements for analyzing tissue damage and destruction. They are:
1. Damage by direct contact with, and static disruption of, tissue.
2. Damage caused by high overpressures in the immediate vicinity of a projectile, penetrating at a high velocity. These pressures are caused by the flow of tissue around the projectile, cause a contusion-and-concussion-type injury.
3. Damage caused by expansion of a temporary cavity, reaching its maximum dimensions long after (milliseconds) the passage of the bullet. The injury is by tear damage, caused by stretching beyond the elastic limit of the tissues, and
4. Damage caused by the collapse of the temporary cavity. This injury could be of a contusion/concussion type caused by the pressure being brought about by the violent collapse of the cavity (implosion). It could also be of a tear/disruption type, caused by instabilities of the interior cavity surface during collapse (Cooper 39).
Senior EMS Paramedic, *edited*, states the first and foremost considerations for the primary caregiver are always the ABC's, airway, breathing and circulation. Then, oxygen and immediate transport. It's also important to learn the trajectory path of the bullet, which you can observe upon finding the exit wound of the bullet, if there is one. Learning of the type of gun involved and the ammunition can serve greatly in helping the doctors in surgery." Emergency Medicine Physician, *edited*, states that, "All gunshot trauma cases are regarded as life-threatening injury until proven otherwise. Regardless of mechanism of injury, in any seriously penetrating gunshot wound, you must assume that the surrounding organs are in jeopardy. The work of the primary caregiver is incredibly crucial from the moment they arrive on the scene. Avoiding aspiration should be one of the strongest primary considerations."
Primary consideration would also be given to possibility of cardiovascular shock. "Therapy must proceed quickly before extensive damage to vital organs can occur" (Dambro 978). Direct pressure on the wound is extremely important in the beginning stages of blood loss. Loss of blood from the said penetrating wound, whether an exit wound is present or not, can result in "inadequate perfusion (oxygen supply) of tissues, which results in organ dysfunction, cellular and organ damage, and, if not corrected quickly, death of the patient" (Dambro 378). This type of shock can manifest itself in different contexts in relation to the type of injury sustained. For example, hypovolemic shock refers to severe reduction of cardiac output due to loss of intravascular volume, most often caused by mostly external blood loss resulting in reduced venous return to the heart. In comparison, distributive shock would be in reference to the maldistribution of blood throughout the body, perhaps from the rendering of a major artery (Dambro 978).
Tests can be given to determine which type of shock has been sustained, including endoscopy/radioisotope bleeding scans. CAT scans, echocardiograms (which may detect and/or quantify pericardial effusions due to pericardial tamponade), lung scans and/or pulmonary arteriography for the detection of vascular injury (including massive pulmonary embolism, as well as pulmonary artery (Swan-Ganz) catheterization for serial measurement of cardiac output, central venous, pulmonary arterial and pulmonary arterial occlusion pressures, and vascular resistance (Dambro 978).
In regards to surgical procedure, each area of the body obviously adheres to specific procedure and technique. Specific regions include the head, thorax, pulmonary, cardiovascular, gastrointestinal, abdominal and extremities. Surgical treatment of wounds to the head involves extreme caution due to risk of imposing further neurological damage. Caution must be given in regards to bone fragments, which may have positioned within the brain.
The neck region contains representations of almost every vital structure, including respiratory, vascular, digestive, endocrine, and neurologic. Heavy blood loss can occur through injuries to the neck region from the carotid artery. The spinal area can also include many serious associated complications, most related to neurologic deterioration and respiratory failure, the latter having a 21% mortality rate (Mattox 464).
Debridement (laying open the wound, as well as removing all non-viable tissue) and excision of all foreign objects and contaminants, especially organic matter, is intitially necessary. Finding the distinguishing line between viable and non-viable tissue can be done using the 'four C's'. These are:
1. Color: a dark-red appearance indicating a lack of oxyhaemoglobin in the tissue, due to poor or absent circulation.
2. Contractility: healthy muscle contracts when touched or pinched.
3. Consistency: a mushy appearance indicating damaged tissue, and
4. Capillary bleeding: when cut, blood from capillaries seeps out into healthy muscle.
Also to be considered is the possibility of deep infections such as traumatic gas gangrene, a form of Clostridial infection that encompasses a possible cause of over 60 gram-positive anaerobic spore-forming rods. This condition results from gas that is produced by the bacteria becoming present in tissue, developing first and most commonly after deep, penetrating and/or crush injury that comprises the blood supply (e.g. gunshot wound). It's incubation period is less than 24 hours but ranges from 6 to 8 hours to several days. Gas present in tissue (as in crepitance) may be obvious in physical examination, soft tissue radiographs, or CT. Associated signs of systemic toxicity develop rapidly, including tachycardia, fever and diaphoresis, followed by shock and multi-organ failure. Bacteremia occurs in 15% of patients and can be associated with brisk hemolysis (the liberation of hemoglobin from red blood cells, brought about by a certain substance acting in conjunction with complement of clotting factor, causing the dissolution of red blood cells and disseminated intravascular coagulation). Complication can include jaundice, hemorrhage, renal failure, hypotension and liver necrosis (Bennett 1631).
Diagnosis of Clostridial Gas Gangrene consists of recognizing pain at the site of prior injury, together with signs of systemic toxicity and gas in the tissue. Definitive diagnosis depends on discovery of large gram-positive rods at the injury site or in the blood. Surgical exploration is essential and demonstrates muscle that does not bleed or contract when stimulated, though in some cases bleeding is a good sign of circulation. Some surgeons will 'nick' the muscle to check for blood flow. Muscle tissue may be edematous and have reddish blue to black discoloration. Treatment includes the administering of penicillin, clindamycin, tetracycline, chloramphenicol, metronidazole, or a number of cephalosporins that have excellent in vitro activity against Clostridia. Aggressive surgical debridement is mandatory to improve survival and prevent further complications. The use of hyperbaric oxygen (HBO) has presented equivocal results when combined with antibiotics and surgical debridement (Bennett 1632).
Patients with a diagnosis of gas gangrene of an extremity have a better prognosis than those with truncal or intra-abdominal gas gangrene, largely because it is difficult to operate on such lesions. It is to be noted that surgical closure of traumatic wounds should be avoided. Antibiotic treatment of such contaminated wounds is extremely necessary and vital. Gas gangrene can also occur in the heart and brain, as well as in the extremities. Other possible deep infections with muscle involvement include streptococcal myositis (muscular discomfort or pain resulting from infection or unknown cause), anaerobic myonecrosis, hemolytic streptococcal infection, acute and infectious staphylococcal anaerobic cellulitis, crepitant phelgmon, and Fournier's gangrene. Aspiration and dissemination of air into wounds by muscular activity and subcutaneous emphysema related to air-leak syndrome or trauma are of concern (Dambro 38).
A survey taken in 1996 by Arthur L. Kellerman, from the New England Journal of Medicine, shows that out of 86 firearm-related injuries, 30% of those were injured in the leg area, 18% were shot in the hands or fingers, and 10% were shot in the feet or toes. Firearm-related injuries sustained in the head, face, neck, chest and abdomen accounted for a combined 23%. The primary type of firearm used was a handgun, with riles and shotguns following far behind, each having a percentage of about 4%. This study was taken from 3 different cities, Memphis, Seattle, and Galveston, and was based on different race/ethnic groups, with most of the incidents occurring within the victim's own homes by the victims themselves.
Anatomical and physiological gunshot trauma can be an immensely complex and intricate condition with possibility of extreme consequence, and should in no way be regarded lightly. Expert medical care is most often required for survival. Survival depends not only on the extremity of the wound, but also as importantly on the care given by EMS first response and the ER/OR constitution of care received thereafter.
References
Bennet and Plum, ed. Cecil Textbook of Medicine. 20th edition. New York: Norton, 1999
Cooper J. Grahama, OBE, PhD, Dudley, Hugh A.F., CBE, MCh, FRCS, Gann, Donald S. MD, Little, Roderick A., PhD, FRCPath, FFAEM, Maynard, Robert L., BSc, MB, BCh, MRCPath, MRCP, ed. Scientific Foundations of Trama. Great Britain: Butterworth-Henemann 1997
Dambro, Mark R, MD, ed. Griffith's 5 Minute Clinical Consult. 9th ed. Philadelphia: Lippincott Williams and Wilkins, 2001.
Ferrera, Peter C. M.D., Colucciello, Stephen A., M.D., Marx, John A., M.D., Verdile, Vincent P., M.D., Gibbs, Michael A., M.D., ed. Trauma Management-An Emergency Medicine Approach. St Louis: Mosby, 2001.
Ferro, Jeffrery. Gun Control: Restricting Rights or Protecting People? (Information Series on Current Topics). New York: Mass Market, 1997.
Kellerman, Arthur L. et al. "Injuries due to Firearms in Three Cities." New England Journal of Medicine, vol.335, no.19. November 7, 1996.
Mattox, Kenneth L., Feliciano, David V., Moore, Ernst E., ed. Trauma. International: McGraw-Hill 2000.
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