2. Objectives
Upon successful completion of this session, student will
be able:
Characteristics of gunshot wounds
Types of gunshot wounds
Types of wounds
Identify relationship between kinetic energy and
prediction of injury
Identify how energy is transmitted from a penetrating
object to body tissue
Identify characteristics of handguns, shotguns and
rifles
Identify organ injuries associated with gunshot
injuries
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3. Objectives cont’d
Identify management goals for a patient with
gunshot wounds
Identify items that could cause stab/penetration
trauma
Identify potential internal organ injuries
dependent on item causing stab/penetration
injury
Identify management goals for a stab/penetrating
trauma patient
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5. CHARACTERISTICS OF GUNSHOT WOUNDS
1. Entrance wounds can be round, oval or irregular (atypical) an
abrasion ring is almost always present.
2. Exit wounds are usually irregular and there is no abrasion ring
in the vast majority of cases
3. The wound mechanism and injury severity are mostly related
to the kinetic energy transferred by the bullet to the tissues
4. Inverted edges due to the bullet movement inside the body
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6. TYPES OF GUNSHOT WOUNDS
1. Penetrating wounds : the bullet enters the body but does not
exit
2. Perforating wounds: the bullet enters and exist the body
3. Re – entry wounds: the bullet passes through a body segment,
exits and re- enters the body
4. Tangential wounds: the bullet strikes the skin at a shallow
angle producing a superficial wound
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7. TYPES OF WOUNDS
A wound is damage to the tissues of the body caused by a
mechanical force. This includes shooting , knifing and explosives
etc.
1. ABRAISON:
This is injury caused by a tangential (at an angle) and
glancing(short lived) force to the superficial layer of the skin that
is epidermis. There is rarely any bleeding because blood vessels
lie in the deeper layer of the skin in the dermis.
2. BRUISES:
These are injuries to the deeper layer of the skin the dermis
caused by blunt trauma. The force caused rupture of the
capillaries in the dermis of the skin which bleeds
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8. TYPES OF WOUNDS CONT
3. LACERATION
This is injury caused by blunt force trauma to the deeper layers
of the skin that is the dermis with associated bleeding. The
wound edges may be tissue bridging (go across) the wound edge.
4. INCISION WOUNDS
These are caused by sharp objects causing injury to the deeper
layer of the skin. There is associated profused bleeding. The
wound edges are sharply demarcated with no tissue bridging.
TWO TYPES OF INCISION WOUNDS
a. SLASH WOUND; The length is greater than the depth
b. STAB WOUND; The depth is greater than the length
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10. Firearm Related Injuries
Gunshot wounds are either penetrating or perforating
wounds
Technical terms:
Penetrating gunshots are when
the bullet enters, but does not
come out of the body.
Perforating gunshots are when
the bullet enters and exits the
body
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13. Entrance wound
Surrounded by
a reddish-
brown area of
abraded skin,
known as the
abrasion ring
Small amounts
of blood
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14. Mechanism of Energy Exchange
As bullet passes through tissue, it decelerates,
dissipating and transferring kinetic energy to tissues
Cause of the injury is the
kinetic energy
Velocity more important than mass in determining how
much damage is done
Small bullet at high speed
will do more damage than
large bullet at slow speed
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15. Mechanism of Energy Exchange
High velocity
High powered rifles; hunting rifles
Sniper rifles
Medium velocity
Handguns, shotguns
Compound bows and arrows (higher energy released)
Low velocity
Knives, arrows
Falling through plate glass window, stepping on sharp objects.
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16. Medium & High Velocity
These items are usually propelled by gunpowder or
other explosive
Faster the object, the deeper the injury
Causes damage to the tissue it impacts
Creates a “pressure wave” which causes damage
frequently greater than the tissue directly impacted
If bone is struck, bone shatters and multiple bone
fragments are dispersed
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17. Low velocity
Usually a result of items such as knives that are
propelled by a person’s own power
Also includes objects inadvertently stepped on
Includes many objects a casualty may be impaled on
Damage usually limited to the area directly in contact
with the object
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22. Projectiles – High Velocity
Rifle bullets are designed to
have much greater velocity
than shotgun bullets
Different size of casing
provides more or less
gunpowder
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23. 7 mm rifle shell – High Velocity
Bonded design for deep
penetration and 90%+
weight retention
Streamlined design
delivers ultra-flat
trajectories
Devastating terminal
performance across a
wide velocity range
Unequaled accuracy and
terminal performance
for long-range shots
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24. Projectiles – Medium Velocity
Shotgun ammunition can
be a variety of kinds
Slugs are one large
bullet in the shell
Some shells contain
numerous pellets of
various sizes
This can influence
casualty’s injuries
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25. Shotgun Shell – Medium
Velocity
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12 Gauge Shotgun Slug 12 Gauge Shotgun with #6 shot
26. .38 caliber pistol ammunition
Controlled expansion to
1.5x its original
diameter over a wide
range of velocities
Heavier jacket stands up
to the high pressures
and velocities of the
highest performance
handgun cartridges
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27. Different Types of Knives
Knives come in a wide
variety of shapes and
sizes
The type of knife can
influence the injuries a
patient may have
Hilt/handle of knife
does not necessarily tell
how long the knife is
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28. Anticipation of Injury
Trajectory may or may not be straight
Knowing anatomy helps anticipate organ injury
Anticipating organ injury helps in knowing what signs
and symptoms to watch for
Anticipation of injury = proactive care
Head wound = monitoring level of consciousness
Chest wound = assessing lung sounds
Abdominal wound = assessing internal blood loss
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29. Stabbings
15 year old stabbed in
the head
Cannot determine from
the outer wound what
the damage is internally
Assume the worse
Stabilization of impaled
objects extremely
crucial
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31. Principles of Wound Care
What are principles of wound care for previous wounds?
Scene safety – even in the ED
Do your ABC Approach
Control bleeding
Usually little to no bleeding while object
still impaled
Prevent further damage
Immobilize the object in place
Gauze, tape, whatever it takes
Reduce infection
Prevent further contamination
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32. Field Management Goals
Critical casualty need rapid transport.
Difficult to assess internal damage in the field
Stop any visible bleeding that could cause hemorrhage
hypovolemia
Address airway issues
Tension Pneumothorax chest decompression
Suction to keep airway open
Intubate to secure the airway
Surgery is the answer to critical gunshots
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33. Field Management Goals
Focus on the basics
If there is a hole – plug it
If there is bleeding – stop it
If they can’t breathe –
ventilate
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Compound bows and arrows are more sophisticated than regular bows and arrows and produce higher energy which makes them a medium velocity weapon.
The focus of EMS is not so much to worry about “what kind of bullet was used” but to focus on the injury at hand to take care of. If the bullet type is known, it is just another piece of information passed onto the hospital staff. EMS should focus on “taking care of the hole”.
Evaluate for chest and abdominal injuries. Not knowing depth or trajectory of stabbing implement, can have organ injury that is angled away from external injury pattern.
