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Gunshot Wounds

Kinematics and Patient Specific


Regional Injuries.

30 December 1997,Mexico
A security guard intending to impress
female friends took a deadly gamble,
losing his life in a game of Russian
roulette at La Paz fast-food restaurant.
Police say Victor, twenty-one, died
instantly on Saturday when he put his .
38-caliber revolver to his head and
pulled the trigger at a suburban
hamburger outlet. Reports state that
Alba was trying to impress some
female friends.
Hoy de La Paz, daily newspaper

Gunshot Wound Statistics


The past decade, 1500 Americans have died
annually from unintentional gunshot wounds.
Unintentional gunshot wounds accounted for
20% of all nonfatal firearm related injuries.
It is estimated that for every person who dies
from an unintentional gunshot wound each
year, almost 13 others are treated in
emergency departments for unintentional,
nonfatal gunshot wounds. (in Sinauer)

Kinematics
Kinematics is the science of motion. In
human movement, it is the study of the
positions, angles, velocities, and
accelerations of body segments. In
gunshot wounds (GSW) we can use this
to determine the extent of injury from
the forces and motion involved.

Injuries Resulting From GSW


There are 3 primary factors that
determine the extent of injury in GSW.
1. Frontal Area.
2. Velocity.
3. Distance.

Frontal Area
Frontal area is the surface area of the
bullet that strikes an object. Factors that
increase frontal area are:
Profile.
Tumble.
Fragmentation.

Profile
Profile
Front

Profile

Front

Bullet before
impact.

Bullet after
impact.

A pointed bullet if
crushed & deformed as
the result of striking the
human body, will have a
much larger frontal area
than before its shape
was changed. A hollow
point bullet is a good
example of this. It
flattens & spreads on
impact, striking more
tissue, creating a larger
cavity & greater injury.

Tumble
A bullets center of gravity is located
nearer to the base than to the nose of
the bullet. When the nose of the bullet
strikes an object it slows rapidly.
Momentum continues to carry the base
of the bullet forward causing an endover-end motion or tumble.

Tumble
Bullets Center of Gravity

There is a greater frontal surface exposed as the missile tumbles & is 90 degrees
to the path. More tissue is impacted & therefore, more energy exchange
occurs resulting in greater tissue damage.

Fragmentation
Bullets with soft noses or vertical cuts
increase damage by breaking apart on
impact. The mass of fragments
produced creates a larger frontal area
than a solid bullet and energy is
dispersed rapidly into the tissues. A
shot gun injury is the ultimate example
of fragmentation.

Velocity
Velocity is a key factor to the overall extent of
GSW injuries.
According to the kinetic energy equation:
(kinetic energy = mass/ 2 x velocity2) Doubling
the mass doubles the energy, however doubling
the velocity quadruples the energy.
Therefore a small-caliber bullet traveling at high
speed can produce a more extensive injury than
larger caliber bullet traveling at a lower speed.

Velocity
Firearms are classified according to
energy level as either:
Medium velocity weapons or
High velocity weapons.

Medium Velocity
These weapons are guns
that have short
barrels,cartridges that
contain small amounts of
gun powder and muzzle
velocities of less than
1500 feet / second.
Example: All Hand guns
& some rifles.
A temporary cavity is
always associated with
medium velocity
weapons. This cavity is
usually 3 to 6 times the
size of the missiles
frontal surface area.
Scott Richey 2001

Medium Velocity Weapons


.

22 Caliber Pistol

Scott Richey 2001

Scott Richey 2001

Medium Velocity Weapons


.

9 mm Pistol

Scott Richey 2001


Scott Richey 2001

Medium Velocity Weapons


.

44 Caliber Pistol

Scott Richey 2001


Scott Richey 2001

High Velocity
High velocity weapons include assault and
hunting rifles with a muzzle velocity of more
than 1500 feet / second.
These weapons use larger cartridges. As the
amount of gunpowder in the cartridge
increases the speed of the bullet increases.
These missiles create a permanent track and
produce a much larger temporary cavity with
the cavity expanding well beyond of the actual
bullet track.

High Velocity Cartridges


30/30

AK-47

AR-15
Scott Richey 2001

High Velocity Weapons

30/30 Hunting Rifle


Scott Richey 2001

High Velocity

AK-47 Assault
Rifle
Scott Richey 2001

High Velocity

AR-15 Assault Rifle


Scott Richey 2001

Distance
Distance is also important in severity of
injury. Air resistance slows the bullet.
Therefore increasing the distance
decreases the velocity resulting in less
kinetic energy.
Unfortunately most victims of GSW
injuries are from close range.

Patient Specific Injuries


The patient in the case study was shot
in the chest (bullet entered right side)
and left lower leg, distal to the proximal
fibula.

Patient Specific Injuries


Considerations
Thorax- Gunshot wounds to the thorax may
result in severe injury to the pulmonary &
vascular systems.
Pulmonary- If the lungs are penetrated by a
bullet, the pleura & pulmonary parenchyma are
disrupted producing a pneumothorax. On
occasion, the pulmonary defect allows air to
continue to flow into the thorax that cannot be
expelled. The subsequent increase in pressure
may eventually cause collapse of the lung
creating a tension pneumothorax.

Thoracic Injuries
Vascular- GSW injuries may result in
massive internal & external hemorrhage.
For example, if the pulmonary artery or
vein, vena cava, or aorta is destroyed,
exsanguination may occur rapidly.
Other injuries include hemothorax,
myocardial rupture, or pericardial
tamponade.

Extremity Trauma
GSWs to the extremities are occasionally life
threatening & may result in disability.
Any GSW to the extremity should be
evaluated for bone injury, motor sensory
integrity, & presence of adequate blood flow.
Special considerations include vascular injury
with bleeding into soft tissues & damage to
muscle, bones, & nerves.

Extremity Trauma
Our patient had extensive trauma to the
left lower leg which required immediate
amputation. However, there are several
scoring systems in place to differentiate
patients who would benefit from primary
amputation versus those patients for
whom salvage of the limb should be
attempted.

Scoring Systems
Mangled Extremity Syndrome Index- Involves point
scales for degree of skin, nerve, vascular & bone
injury,injury severity, age, concurrent medical
conditions & time to vascular repair. (Requires
surgical intervention for accurate determination)
Predictive Salvage Index- Use with lower extremities,
this system assigns points for the level of an injury,
degree of bone & muscle injury & interval before
arrival in the operating room.
Limb Salvage Index- Based on duration of ischemia
& severity of injury to artery, bone, muscle, skin,
nerve & deep veins.

Scoring Systems
Mangled Extremity Severity Score (MESS)System is based on degree of skeletal, soft
tissue injury, ischemia, shock & age.
Simple to apply.
Most of the information is available at the
initial evaluation.

Mangled Extremity Severity Score (MESS)

Skeletal/ Soft-tissue Injury


Low energy (stab, simple fracture, pistol gunshot wound) 1
Medium energy (open or multiple fractures, dislocation)

High energy (high speed MVA or rifle GSW)

Very high energy (high speed trauma + gross contamination)

Mangled Extremity Severity Score (MESS)

Limb Ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless, paresthesias, diminished capillary refill 2
Cool, paralyzed, insensate, numb 3*
* Score doubled for ischemia > 6 hours *

Mangled Extremity Severity Score (MESS)

Shock
Systolic blood pressure > 90 mmHg 0
Hypotensive transiently 1
Persistent Hypotension 2

Mangled Extremity Severity Score (MESS)

Age (years)
< 30 0
30-50 1
> 50 2

Scoring Systems
All of the scoring systems are able to identify
the majority of patients who require
amputation.
None of the scoring systems are able to
predict functional outcome.
None of the predictive scales have been
adequately validated. They should only be
used as guides in conjunction with the
surgeons judgement & experience.

Reference
American College of Surgeons Committee on Trauma: Advance
Trauma Life Support Program. Chicago. 1999
America Trauma Society. Trauma Facts.
Bonanni, F. The Futility of Predictive Scoring of Mangled Lower
Extremities. Journal of Trauma. Jan 1993, v 36 p 99-103.
Durham, R. Outcome and Utility of Scoring Systems in the
Management of the Mangled Extremity. The American Journal of
Surgery,Nov 1996 v 172 p 569.
Moylan, J. Pulmonary Chest Trauma: Principles of Trauma
Surgery, New York 1997.
Pons, P. Pre-hospital Advanced Trauma Life Support for Critical
Penetrating Wounds to the Thorax and Abdomen. Journal of
Trauma, 1985 v 25.
Sinauer, N. Unintentional, Nonfatal Firearm-Related Injuries: A
Preventable Public Health Burden. JAMA, Jun 12, 1996, v 275, p
1740.

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