Shootings: Treatment Tips, Shotgun Injuries, Perfusion Support & Bullet Design

GUNSHOT WOUND TREATMENT TIPS

• Medication administration may be indicated. The decision should be guided by the patient's overall condition and local protocols. For example, if a sober adult patient has been shot in the hand and is experiencing profound pain, analgesia may be appropriate.^1,2
• The use of restraints, physical or chemical, may be indicated as well. Restraints may be used to help minimize patient movement or help protect the patient from additional injury. If restraints are used, providers should clearly document the method selected and the reason it was necessary. Frequent reassessment of the patient's overall status is critical.^1,2
• When responding to reported gunshot wounds, providers may want to monitor the radio transmissions of other agencies, including local law enforcement. This can keep them updated on scene developments. Providers may be able to communicate directly with other agencies; this can be invaluable in coordinating on-scene activities.
• A paper bag might be placed over the hand(s) of the patient while the patient is being assessed and managed. This can help preserve evidence, such as gunpowder residue, that might be on the hand(s). This is not routinely done in all EMS systems, so check with your system's guidelines.
• Prehospital spinal immobilization in cases of gunshot wounds continues to be discussed in the medical literature. As recently as January, there was an article in the Journal of Trauma that questioned the need for, and even suggested potential harm from, prehospital spinal immobilization of victims of penetrating trauma. Consult your local protocols.³

References

1. Dries DJ. Initial Evaluation of the Trauma Patient. eMedicine, http://emedicine.medscape.com/article/434707-overview.

2. Miglietta MA. Trauma and gunshot wounds: What you need to know to save a life. Tactical Medical Packs, www.tacticalmedicalpacks.com/files/Combat_Tactics_Trauma_article.pdf.

3. Haut ER, Kalish BT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma 68(1): 115-121, Jan 2010.

SHOTGUN INJURIES: THE IMPACT OF PELLET DISPERSAL

Shotguns are a specific type of firearm that deserves special consideration. A shotgun, sometimes called a scattergun, involves a shell that normally contains small spherical pellets, or shot. A combination of items, such as a slugs or flechettes, can also be used.^1-5 In contrast to handguns and rifles, shotguns do not have rifled barrels. As a result, shotgun pellets do not spin.⁶

When a shotgun is fired, the contents of the shell spread apart as they leave the barrel. This disperses the power of the charge. As the pellets' area of distribution increases, the energy in each pellet decreases. This means the energy of any single pellet is lower than if all the energy of a blast were contained in a single pellet or bullet.³ Differences in range (the distance between the firearm and the target) affect the wounding potential of shotgun pellets more than bullets.

At close range, shotgun injuries can be more severe than bullet injuries because damaging amounts of energy are partially dispersed rather than concentrated. When the masses of multiple pellets are combined and spread over a small area, massive destruction can result. In addition, in contact injuries, the mass of the pellets combined with the combustion of gases can cause significant damage. Close-range shotgun injuries are less predictable than those from longer range, with factors such as anatomic location and pellet density influencing them. At greater range, the wider spread and lower velocity of the pellets tends to produce widely separated and superficial injuries that may be painful but not necessarily life-threatening.

References

1. Stanton-Maxey KJ, Bjerke HS. Abdominal Trauma, Penetrating. eMedicine, http://emedicine.medscape.com/article/433554-overview.

2. Evans MB. Gunshot Wound Ballistics. Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, www.bcm.edu/oto/grand/02_12_04.htm.