Gunshot Wound: Symptoms, Pathophysiology, Diagnosis, Treatment and Prevention

A gunshot wound (GSW) is a puncturing injury brought on by a projectile, such as a bullet, fired from a gun, usually an air gun or rifle. Infections, wounds, haemorrhage, bone fractures, organ damage, loss of movement in some parts of the body, and in extreme situations, even death, are possible damages. Damage is determined by the area of the body struck, the bullet's kind and velocity, and the course it takes through the body. 

Bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, amputations, hypoxic brain injury resulting in early dementia, hyperalgesia (chronic pain with light touch), deep vein thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning are examples of long-term complications.

Each nation has different factors that influence gun violence rates. The illicit drug trade, easy access to weapons, substance abuse, including alcoholism, mental health issues, gun control legislation, societal perceptions, disparities in income, and professions like law enforcement are a few examples of these variables. More frequently than not, altercations involving weapons result in fatalities.

The location has to be confirmed as safe before management gets started. Stopping significant bleeding comes next, and after that, the airway, breathing, and circulation are evaluated and supported. Gun regulations reduce the probability of firearm-related deaths, especially those about background checks and permits for purchases. The likelihood of child fatalities with firearms may be reduced with safer weapon storage.

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Symptoms Of Gunshot Wound

Based on the bullet, its velocity, mass, entrance site, trajectory, damaged anatomy, and exit point, the trauma from a gunshot wound varies greatly. Compared to other penetrating injuries, gunshot wounds can be more dangerous due to the unpredictable trajectory and fragmentation of bullets once they enter the body. 

Furthermore, a significant amount of adjacent tissue disruption and destruction is usually present in gunshot wounds due to the projectile's physical impacts, which are associated with the bullet velocity categorization.

A gunshot wound usually causes substantial bleeding very away and raises the risk of hypovolemic shock, which is a situation where there is not enough oxygen getting to the critical organs. Since blood is the way by which oxygen is delivered to the body's constituent parts, blood loss is the cause of inadequate oxygen delivery in the event of acute hypovolemic shock. 

When a bullet penetrates a crucial organ like the heart, lungs, or liver, or damages a part of the central nervous system like the brain or spinal cord, devastating consequences may ensue.

Following a gunshot wound, haemorrhage, pneumothorax-induced low oxygen, severe damage to the heart and major blood arteries, and harm to the brain or central nervous system are among the common causes of death.

 In addition to usually resulting in some sort of serious deformity, such as amputation due to a severe bone fracture, non-fatal gunshot wounds can have mild to severe long-lasting consequences that may cause chronic impairment. If a bullet directly hits bigger blood vessels, especially arteries, the resultant consequence might be an abrupt outpouring of blood.

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Pathophysiology Of Gunshot Wound

The amount of cavitation a bullet produces as it travels through tissue determines how much tissue disruption it causes. A bullet with enough energy will not only cause penetrating track damage but also cause cavitation. The permanent cavity occurs in the area left behind by the bullet as it goes through the tissue, first crushing and then severing. 

Bullets with higher muzzle velocity generate a pressure wave that pushes the tissues aside, resulting in a temporary or secondary cavity that is frequently much bigger than the bullet itself, as well as a permanent cavity the size of the bullet's calibre. 

Due to strong pressures surrounding the projectile that propel material away from its route, the radial stretching of tissue around the bullet's wound track creates a temporary hollow in the tissue. The following attributes of the projectile are correlated with the degree of cavitation:

• KE = 1/2mv2, where m represents mass and v is velocity, is the formula for kinetic energy. This helps to explain why wounds caused by projectiles with higher mass and/or velocity cause more tissue disruption than wounds caused by projectiles with lower mass and velocity. One other significant factor influencing tissue damage is the bullet's velocity. 
• Although the projectile's total energy is a function of both mass and velocity, the energy is proportional to mass and square of velocity. Because of this, if the mass doubles at a constant velocity, the energy also doubles; if the bullet's velocity doubles, the energy increases four times. A bullet's starting velocity is mostly determined by the kind of weapon. 5.56-mm bullets are often used by the US military; they are comparatively fast-moving projectiles with a low mass when compared to other rounds. They thus generate more kinetic energy, which is transferred to the target's tissues. 
• The temporary cavity's size is determined by the tissue's ability to withstand stress and is roughly proportionate to the bullet's kinetic energy. For simplicity of comparison, muzzle energy which is dependent on muzzle velocity is frequently utilised.
• Yaw: When a handgun bullet strikes a bone, it usually travels in a fairly straight line or makes one spin. High-energy bullets may become unstable as they slow down and may fall (pitch and yaw) when the projectile's energy is absorbed, straining and ripping the surrounding tissue as it pass through deeper tissue.
• Fragmentation: Bullets don't fragment very often, and fractured bone fragments more frequently cause secondary injuries than bullet fragments.

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Diagnosis Of Gunshot Wound

Gunshot wounds are categorised using the Gustilo open fracture classification based on the projectile's speed:

• Low velocity: less than 1,100 feet per second (335 metres per second)
• Low-velocity injuries resemble Gustilo Anderson wound patterns and are common with small-calibre pistols. type 1 or type 2 injuries.
• The range of a medium velocity is 1,200 feet per second (366 metres per second) to 2,000 feet per second (610 metres per second).
• Higher calibre pistols, such as magnums, or shotgun bursts are more common for them. Based on the kind and pattern of bullets fired, the distance from the firearm, and other factors, the risk of infection from these kinds of wounds can change. High speed: From 2,000 feet per second (610 metres per second) to 3,500 feet per second (1,067 metres per second)

Typically produced by powerful hunting or assault weapons, these wounds resemble Gustilo Anderson Type 3 wounds in terms of their pattern. Because of the extensive damage and damaged tissue, there is an increased risk of infection.

While most contemporary rifle bullets surpass 2,500 feet per second (760 metres per second), handgun bullets are occasionally less than 1,000 feet per second (300 metres per second). However, with current pistol loads, they are often somewhat above 1,000 feet per second (300 metres per second). The hyper-velocity bullet is a newly invented type of firearm projectile. These cartridges are often either factory ammunition or wildcats intended to reach such high speeds. 

Nevertheless, one must keep in mind that high kinetic energy does not always translate into high stopping power since bleeding and other distant wounded effects are more common causes of incapacitation than direct energy transmission. 

While increased tissue disruption brought on by high energy does contribute to incapacitation, other criteria like wound size and shot location are just as important, if not more so, in determining stopping power and efficacy. For ease of comparison, muzzle velocity does not account for the impact of aerodynamic drag on the bullet's flight.

The Kronlein shot

A unique kind of headshot wound known as a "Kronlein shot" may only be caused by a high-velocity rifle bullet or shotgun slug. The complete brain is expelled from the skull and placed at a distance from the victim's body in a Kronlein shot. Hydrodynamic effects are thought to be the source of this kind of wound. The brain explodes out of a broken skull as a result of hydraulic pressure created within the skull by a high-velocity bullet.

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Treatment Of Gunshot Wound

A gunshot wound is initially assessed using the advanced trauma life support (ATLS) procedure, much like any other acute trauma. Among them are:

1. Airway: Evaluate and safeguard the airway, as well as the cervical spine;
2. Breathing: Ensure sufficient ventilation and oxygenation
3. Circulation: Use targeted sonography examination for trauma assessment together with bleeding control measures to preserve organ perfusion (FAST)
4. Disability: Complete a basic neurological examination, taking the Glasgow Coma Scale into account (GCS)
5. Exposure: While preserving body temperature, expose the full body and look for any overlooked wounds, entrance, and exit locations.
   The course of treatment might vary from immediate surgery to close observation, depending on the severity of the damage. Therefore, any information gathered at the site, including the type of gun used, the number and direction of rounds fired, the amount of blood lost there, and the pre-hospital vital signs, might be highly useful in guiding management. Individuals who are unstable and have bleeding symptoms that are uncontrollable during the initial assessment need to be operated on very early. If not, anatomic entry point and projected trajectory often influence treatment measures.

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Prevention Of Gunshot Wound

Medical organisations in the US advise against allowing someone with a violent criminal conviction to purchase a firearm and in favour of holding a criminal background check before making such a purchase. Better mental health care, the removal of firearms from suicidal individuals, and safe storage of firearms are also advised. Stricter laws on firearms with high burst capacity are advised in an attempt to stop mass shootings.

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