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Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022
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Image courtesy of Nicole Cimino-Fiallos, MD.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
The above patient experienced multiple gunshot wounds, including to the left leg. One bullet caused a displaced, comminuted fracture to his femur (green arrow). A retained bullet fragment is also seen (white arrow).
Research indicated that between 2009 and 2017, there were 329 firearm injuries in the United States per day.[1] Moreover, US gun deaths have risen, with 45,222 in 2020, a 43% increase from 10 years before. Of these, 19,384 (43%) represented murders, while 24,292 (54%) resulted from suicide, with per capita gun deaths reaching 13.6 per 100,000 people.[2]
Image from Katzilakis N, Michalakis M, Vlachakis J, et al. Cases J. 2009;2:6340. [Open access.] PMID: 19829790, PMCID: PMC2740203.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
Stray lead pellets can be seen in this radiograph of a young boy who was accidentally shot by an uncle who was cleaning a shotgun. Over 200 pellets were counted on radiographs of the child's thorax, abdomen, and limbs.
Data from the United States National Vital Statistics System and the National Electronic Injury Surveillance System indicate that 5790 children are treated annually for firearm-related injuries.[3] In 2020, firearm-related injuries were the leading cause of death in children and adolescents in the United States aged 1-19 years.[4]
Image courtesy of Nicole Cimino-Fiallos, MD.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
The above computed tomography (CT) scan is from a patient with multiple gunshot wounds to the chest, abdomen, and pelvis. Retained bullet fragments are seen (green arrow), as are gas bubbles (blue arrow), with the latter raising concern for luminal injury.
Firearm-related injuries, when not fatal, cause significant morbidity. In general, the abdomen and extremities are the most frequent wound sites, but the head, neck, and thorax are also often affected.[5,6] Between 1993 and 2015, out of an estimated 2,667,896 emergency department (ED) visits in the United States due to firearm injuries, 10,296 (0.4%) involved the spine.[7]
Image from Krausz AA, El-Naaj IA, Barak M. World J Emerg Surg. 2009;4:21. [Open access.] PMID: 19473497, PMCID: PMC2693512.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
A woman sustained a single high-velocity, long-distance firearm injury to the right cheek, with severe soft-tissue damage. A comminuted fracture of her right orbit, zygoma, and mandible is demonstrated on this three-dimensional CT scan.
Image courtesy of Nicole Cimino-Fiallos, MD.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
Head Wounds
The above CT scan shows a patient who sustained a gunshot wound to the right face. He had multiple comminuted fractures of the temporal and parietal bones (green arrow), an epidural hematoma (white arrow), an intracerebral hemorrhage (blue arrow), and a subarachnoid hemorrhage (orange arrow), with associated brain edema.
Clinicians cannot reverse the initial injury from a gunshot wound to the head; they can only attempt to limit the amount of secondary damage to the brain from swelling, ischemia, and hypoxia.
Preventing hypotension and resultant ischemia is critical to a patient's survival, as mortality doubles if hypotension develops.[8] Even with optimal management, however, mortality is significant (88-93%) in patients with firearm-related craniocerebral injuries.[9]
Image from Rosenfeld JV, Bell RS, Armonda R. World J Surg. 2015;39(6):1352-62. [Open access.] PMID: 25446474, PMCID: PMC4422853.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
This intraoperative craniotomy photograph shows a gunshot wound to the left parietal lobe. The dura has been opened. Swollen brain surrounds the bullet's gross hemorrhagic track. Dirt contaminated the wound.
Image from Ongom PA, Kijjambu SC, Jombwe J. J Med Case Rep. 2014;8:29. [Open access.] PMID: 24467784, PMCID: PMC3917526.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
Neck Wounds
The patient in this head-and-neck CT scan through the median sagittal plane sustained an atypical, accidental AK-47 rifle injury to the right side of the face and neck. Note that the bullet migrated cephalad to lie partially anterior to the fifth cervical vertebra. The comminuted fracture of the right mandible's angle and ramus is also seen.
A penetrating wound to the neck can damage an individual's larynx and/or trachea, which can obstruct the airway.[10] Evaluate patients for voice changes, hemoptysis, cyanosis, and/or difficulty breathing; the presence of any of these signs of laryngotracheal injury should prompt emergent intubation. If orotracheal intubation fails, a cricothyroidotomy should be performed.[10]
Images from Ministrini S, Baiocchi G, Pittiani F, Lomiento D, Gheza F, Portolani N. World J Emerg Surg. 2015;10:52. [Open access.] PMID: 26561497, PMCID: PMC4641384.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
An elderly male suffered a gunshot wound to the head, with only a single visible bullet hole found at the back of the neck. These contrast-enhanced CT scans show a large subdural hematoma and a retained bullet in the brain (left image); a retained projectile in the left lung (center image), with no demonstration of thoracic wall wounds; and the presence of peritoneal free fluid (right image).
Image courtesy of Nicole Cimino-Fiallos, MD.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
Thoracic and Abdominal Wounds
The above CT scan shows a patient who presented with multiple gunshot wounds to the chest, abdomen, and pelvis. The patient has a right-sided pneumothorax (white arrow) and hemothorax (yellow arrow), with a shattered right sixth rib (green lines) and retained bullet fragments (blue arrows). A contused lung is also shown (orange arrow).
Gunshot wounds to the chest can be lethal if they damage the heart, lungs, great vessels, bronchial tree, or esophagus.[11,12] If the patient is unable to talk or has hemoptysis, subcutaneous emphysema, or respiratory distress, tracheobronchial injury may be present. The patient should be urgently intubated, and emergent bronchoscopy and operative intervention may be required.[12]
Images from Lu K, Gandhi S, Qureshi MA, Wright AS, Kantathut N, Noeller TP. West J Emerg Med. 2015;16(4):489-96. [Open access.] PMID: 26265959, PMCID: PMC4530905.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
These images were obtained in an adult male who sustained nine gunshot wounds from two assailants with handguns.
In the chest radiograph on the top left, a blurred foreign body lies within the cardiac silhouette (arrow). The apical view of the right ventricle (RV) on transesophageal echocardiography (top right) reveals that the bullet tip is in the right ventricular trabeculae (arrow).
In the bottom row, the chest CT scans demonstrate transverse (image A) and sagittal (image B) views of the bullet (arrows) in the RV, with the presence of significant glare.
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
This abdominal sagittal radiograph shows a ballistic fragment resting against the spine after penetrating the abdomen.
Patients who present to the ED after experiencing a gunshot wound to the abdomen should undergo a primary trauma survey (ABCDEs: airway, breathing, circulation [including bleeding control], disability [mental status], and exposure/environmental control) and resuscitation.[13]
Note that gunshots can penetrate the abdomen even if they enter the body from elsewhere, such as the pelvis or chest. Therefore, inspect all body surfaces, especially the axillae, groin, and buttocks. Document all penetrating wounds.[13]
Image courtesy of Nicole Cimino-Fiallos, MD.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
This abdominopelvic CT scan was obtained in a patient with a shotgun wound to the abdomen that damaged the liver, colon, and mesentery. The red arrows reveal shotgun pellets; the yellow arrow indicates blood.
Most, but not all, patients with a substantial penetrating injury to the abdomen will require emergency surgery to explore the peritoneal cavity for damage. Note that, unlike the implements of other types of penetrating trauma (eg, knives), bullets travel at high speeds and can ricochet, resulting in nontangential injury patterns. Hemodynamically unstable patients with abdominal gunshot wounds would likely benefit from an exploratory laparotomy.[14]
Images from Jaha L, Ademi B, Ismaili-Jaha V, Andreevska T. J Med Case Rep. 2011;5:354. [Open access.] PMID: 21819587, PMCID: PMC3169494.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
A patient was shot in the back, which resulted in fractures of his twelfth thoracic and first lumbar vertebrae, wounding of the posterior wall of the abdominal aorta, and a bullet embolism in the left external iliac artery. The left image shows a bullet in the left iliac fossa and another in front of the sacrum. The right image, in the same patient, depicts a bullet's extraction from the left common iliac artery.
Image from Todd E Rasmussen, MD and James G Smirniotopoulos, MD, Uniformed Services University, via MedPix.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
Vascular Wounds
The above military service member had active arterial and venous bleeding from a penetrating gunshot injury. Tourniquets are in place.
The leading cause of death in victims of penetrating trauma is exsanguination.[15] The American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) guidelines support the use of tourniquets to control extremity hemorrhage, recognizing that direct compression is not sufficient to stop some arterial hemorrhages.[16]
Image from Todd E Rasmussen, MD and James G Smirniotopoulos, MD, Uniformed Services University, via MedPix.
Gunshot Wounds: Damage and Death
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | April 8, 2022 | Contributor Information
This intraoperative image was obtained in the same patient seen in the previous slide. The gunshot completely penetrated the right thigh, disrupting the superficial femoral artery and vein. Temporary Javid shunts were placed in both injured vessels before the patient was evacuated to a military hospital. The green floor of the surgical suite can be seen below the vessels.
The use of tourniquets has been translated from the battlefield to civilian ambulances and EDs. Although these devices can cause occasional complications such as compartment syndrome and distal ischemia, tourniquets have been shown to decrease hemorrhage and save lives.[17,18]
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Contributor Information
Author
Nicole Cimino-Fiallos, MD, FACEP, FAAEM
Emergency Medicine Specialist
US Acute Care Solutions;
Assistant Medical Director
Emergency Department
Meritus Medical Center
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, FACEP, FAAEM, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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Offner P, Stanton-Maxey KJ, Bjerke HS. Penetrating abdominal trauma. Medscape Drugs & Diseases from WebMD. Updated: May 26, 2021. Available at: http://emedicine.medscape.com/article/2036859-overview. Accessed March 28, 2022.
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