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Gunshot injuries

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 Gunshot injuries
Vivek Agrawal, Mohit Kumar Joshi

Learning Objectives

1. Burden of gunshot injuries in our country

2. Overview of firearms
3. Basics of a firearm: the anatomy of
a. Gun
b. Ammunition
4. Gunshot injury patterns
5. How to record a gunshot wound: the medico-legal implications
6. Management of a patient with gunshot injury
Introduction

Gunshot injuries constitute a small number as compared to all other modes of injuries (how many
patients with gunshot injury do you encounter during a routine call day in surgical emergency as
compared to all the trauma patient you manage that day?). Despite their relative infrequency, gunshot
injury retain the pride of place among all the mechanical injuries because of a large number of arms
from which they may be fired, varied injury patterns they produce, their often fatal consequences and
associated medico-legal consequences.

Management of a patient with gunshot injury follows the same principles as that of any other patient of
trauma so it may not be much difficult to manage such patients surgically. The thing which the treating
doctor might find difficult and which is so intimately associated with the overall management of a
patient with gunshot injury is the basic knowledge of firearms, preparation of an injury report with
regards to different injury patterns of gunshot injury and different nomenclature associated with this
special kind of assault. In addition, there always is a fear of associated medico-legal implications. We
feel that this ‘fear’ is valid as what all we are taught regarding gunshot injuries during our training as
doctors constitutes a small part of forensic medicine as a subject (unfortunately there is no formal
teaching or training in this specialized area of jurisprudence after medical graduation).

In the present article we intend to explain the basics of firearms, their injury patterns and preparation
of injury report of a patient with gunshot injury in a simple way. We hope that this effort will alleviate
the ‘fear of unknown’ associated with the gunshot injuries to some extent. We will also discuss in
short the principles in managing a patient with gunshot injury.

Guns and gunshot injuries in our country

Although the latest statistics suggest that the incidence of firearm related crime has declined over the
past decade in our country,1 still the burden of firearm related injury remains high. A large number of
persons die and many more survive with disabilities following gunshot injuries. In addition the social
stigma associated with the gunshot injury and the financial burden of fighting an often lengthy medico-
legal case (which may run through years) make the matter worse for the sufferers and their family.

Possession of firearm in our country is controlled by law. No one can just acquire a firearm without
explaining to the law officials the compelling reason for its acquisition and without obtaining a valid
arms license which follows rigorous scrutiny (or this is believed at least). However, there are a large
number of illegal factories which manufacture wide variety of guns that range from highly
sophisticated weapons to improvised guns made from crude pipes and local firing mechanisms
(known as country made weapons). In an estimate the total number of guns held by civilians (means
those excluding the defense and the police personnel) in India is 40,000,000, however the number of
 2
issued arm licenses are 6,30,000. This amounts to a staggering figure of 33,700,000 unlawfully held
guns in our country (mind you this is just an estimate, the true number may be much more than this).

The presence of such varied types of firearms and the myriad of injury they produce makes the job of
treating surgeon and the forensic expert truly challenging. On one hand the appearance of wounds
produced by such country made weapons usually shows deviation from the established gunshot
wound patterns produced by the licensed weapons (which conform to manufacturing specifications)
and thus may confuse the surgeon while recording the injury; on the other hand forensic and ballistic
expert may find it difficult to estimate the bore of the weapon and the distance from which the shot is
fired as these weapons do not follow the size and kinetics of a standard firearm. Moreover, assailants
can easily dispose such weapons without much financial loss and, therefore, these guns cannot be
traced to an owner. According to the latest report of National Crime Record Bureau (NCRB), in year
2012, 3781 persons were murdered by guns, of which only 323 were killed by licensed weapons and
3
rest 3458 (nearly 90%) were killed through the use of unlicensed guns.

Anatomy of a firearm: general considerations

A basic understanding of guns and ammunition is essential and is complimentary in managing
patients with gunshot injuries. As previously discussed, a large variety of guns are available. A
detailed description and subtle modification of all firearms is beyond the scope of the present article,
however the general description of components of a basic firearm is as follows.

1. Barrel: Every firearm consists of a hollow metal pipe called barrel which is closed at one end and
is open at the other. The open end is called the ‘muzzle end’ and the closed end the ‘breech end’.
The guns in which the cartridge is loaded from the muzzle end are called ‘muzzle loaders’
whereas the ones in which the cartridge is loaded from the breech end are known as ‘breech
loaders’. All authorized gun manufacturers make breech loading guns that strictly adhere to the
specified norms. The barrel of a breech loader has three parts. From breech end to the muzzle
these include-
a. Chamber: is part of barrel which is meant to hold the cartridge. It is larger in diameter
than the rest of the barrel. On its posterior aspect there is a small metal part called the
‘breech block’ which can be opened to load a cartridge in the barrel and is closed
following loading.
b. Taper: also called ‘lead (or leed)’ in rifled firearm and ‘chamber cone’ in smooth bore
weapons is the intervening part of barrel between the chamber and the bore.
c. Bore: is the rest of the barrel up to the muzzle. Bore might have spiral grooving from
inside in case of rifled firearms or it might be smooth in case of smooth bored weapons.
2. Breech action: is the part of a firearm that loads, fires, and ejects a cartridge. Various
firearms have different mechanisms that may constitute lever action, pump action, bolt action,
semi-automatic and automatic action.
3. Breech face: is the flat part of the breech block that seals the breech end of the barrel. It is
pierced in the centre to accommodate the firing pin.
4. Hammer and firing pin: Hammer is a metal rod or plate that is attached to a pointed metal
structure called firing pin. Hammer is attached to the trigger with a spring action. When the trigger
is pressed hammer is released, moves forward with great speed and the firing pin strikes the
cartridge through the hole in the breech face.
5. Stock: is the supporting part or simply the handle of the firearm. The end of the stock is
called the ‘butt’. Usually the stock of the gun accommodates the action and the trigger mechanism
of the weapon. In the hand held firearms, stock is provided with grips which facilitate the grasping
of a firearm. In long barreled weapons the butt is elongated and contoured to fit on the shoulder.
6. Safety catch: is a safety device present in all firearms (except revolver and improvised
country made guns). When activated this locks the firing mechanism. It needs to be released
before the shot can be fired.

The functioning of a firearm: How it fires a shot?

A cartridge (or shot) is loaded to the chamber of a gun and the chamber is closed for firing (the
maneuver to close the chamber may differ with the breech action of the firearm being used). Once
closed, the barrel comes into position along the breech face. The weapon is then cocked (ready to be
fired), this pulls back the hammer and attached firing pin against a strong spring and is held there
resting on a small notch. When the trigger is pressed, the hammer disengages from the notch and
due to the spring action moves forcibly forward to strike the firing pin. This in turn strikes the back of
the cartridge through the hole in the breech face igniting the powder that the cartridge contains. This
creates an explosion and the gases so produced generate enough energy that propels the projectile
(bullet or pellets) in the cartridge with great speed forward through the muzzle of the weapon.

Due to this explosion flame, smoke, unburnt and partially burnt powder are produced that also leave
the barrel through the muzzle end and travel up to varying distances when the weapon is fired. If they
happen to come in contact with the victim’s body, they may leave their imprint on the skin, and this
forms the basis of estimation of the range of fire during criminal investigations.

Classification of firearms: Rifled or smooth bored

weapons
The firearms are broadly classified into rifled or smooth
bored ones depending on whether the inside of barrel
contains spiral grooving (called rifling) or not. In rifled
weapons the inside of the barrel contains a number of spiral
grooves which run parallel to each other but are twisted
spirally from breech to muzzle end (Figure 1 a & b). The
grooves are called ‘rifling’ and the projecting ridges between
the grooves are called ‘lands’. The distance between the two
diagonal lands is called ‘calibre’ that denotes the size of the
rifled weapon (Figure 1 a). The guns which do not have
these riflings in their barrel are called smooth bored
weapons or ‘shot guns’. The size of the smooth bore
weapon is designated by gauze.

Why some weapons are rifled?

When a bullet passes through the bore of a rifled firearm,
the bullet acquires a spinning motion. This bullet comes out through the muzzle end with great speed
spinning on its own axis. This spinning motion gives the bullet

a. Greater power of penetration.

b. Straight trajectory towards the target.
c. Steady movement while the bullet travels in air.

The rifled firearms therefore can strike to a greater range with better accuracy and because of the
greater speed and penetrating power of their projectile, are more lethal than their counter part - shot
guns. In smooth bored weapons (the shot guns), the projectile does not get this spin and therefore the
range and accuracy of the projectile is comparatively less. This does not mean that the shot guns are
any less lethal. From a limited range they are either as much or may be more lethal than the
sophisticated rifled firearm.

Common types of firearms used in India

Although the assailants cherish a variety of sophisticated and improvised guns in India, four types of
firearms are most commonly used. These include revolver, semi-automatic pistol, rifle and shot guns.
Out of these revolvers, semi-automatic pistols and rifles are rifled weapons whereas shot guns are
smooth bored weapons.

1. Revolver: is a hand held gun with a rifled barrel. It contains a revolving chamber that usually
accommodates six cartridges (however the number may vary from 4 to 12). With each fire the
chamber revolves and brings the next cartridge in line with the barrel ready to be fired.
2. Semi-automatic pistol: This again is a hand held gun which is rifled. However unlike a
revolver it does not contain a revolving chamber. A number of cartridges (5-30) can be loaded in
the magazine housed in the hollow hand grip of the gun. Once a shot is fired, the spent cartridge
is ejected from the weapon and the chamber is replaced by a fresh cartridge from the magazine
automatically, making the gun ready for the next shot. Are you wondering then why this arm is the
not called an automatic gun? This is because only one shot is fired once the trigger is pulled. For
the next shot the trigger needs to be pulled again. In a truly automatic weapon, the gun keeps on
firing cartridges as long as the trigger is kept pulled. Machine gun is a typical example of a truly
automatic weapon; however a truly automatic pistol virtually does not exist.
3. Rifle: This is a firearm with a long rifled barrel and a relatively large stock. Unlike its rifled
hand held counterparts (revolver and semi-automatic pistol), a rifle is designed to fire with two
hands while the stock is supported on the shoulder. As the length of the barrel is directly
proportional to the velocity and the stability of the ejected projectile, the rifles can fire to a greater
distance with more accuracy than the weapons with smaller barrels.
4. Shotgun: A shotgun is a weapon that is designed to be held by both hands with stock resting
on shoulder (same as a rifle). The biggest difference from the other weapons is that the inside of
the barrel of this gun is smooth and does not contain rifling (that is why it is also called a smooth
bored weapon). They come in different designs varying from manually loaded single or double
barrel guns to self loading guns.
Although the barrel of a shotgun is smooth but to
produce the concentration of the shot, the distal 3-4
inches of barrel of a shotgun may have a contraction
known as ‘choke’ (Figure 2). Depending on this degree
of contraction, the choke is variably referred as full,
half or quarter choke. The benefits of choking are :-
a. Decreases the extent of spread of the shots (more choke, thereby concentrates the shots
towards the target).
b. Increases the explosive force of the projectile and thereby increases the velocity and
penetrating power of the shots.
As previously mentioned the range and accuracy of a shotgun is less, however the cone like
spreading of the shots coupled with their large numbers makes this weapon lethal in short range.

Ammunition used in firearms

Ammunition used in firearms comprises following parts-

1. Missile: is a bullet in case of a rifled firearm and shots

(pellets) in case of a shotgun. A bullet is made up of lead
which usually is hardened by alloys of Antimony and Barium
and is mounted on a cartridge case. To further harden them
the bullets may be covered by a ‘jacket of metal alloy’.
Depending on the extent of jacketing, the bullets may be
unjacketed, semi-jacketed or fully jacketed.
The shots are in the form of small lead balls or pellets
contained in a shotgun cartridge. Like bullets, alloys may be
used to harden them which increase their penetrating power.

2. Cartridge: The cartridge is a hollow cylinder which holds together the missile, powder, primer
and ignition cap. It is made up of brass for use in rifled
weapons and paper and brass for use in shotguns (Figure 3 &
4). When a gun is fired, the cartridge case falls at the scene
and the bullets (or shots) move to a varying speed (depending
on the type of weapon) towards the target, thus cartridge case
may serve as an evidence in forensic investigations and may
help identify the weapon from which it was fired.

3. Primer: The primer is a small amount of stable but highly

shock sensitive explosive material commonly made up of lead
azide or potassium perchlorate. This small amount of charge is
 housed in small copper or brass cup on the bottom of the cartridge case. When the trigger is
pulled, hammer and the firing pin move forcibly forward and strike the primer with a crushing blow.
The charge gets ignited by this blow and the flames so produced explode the main powder
charge.
4. Powder: is the chemical material that when undergoes combustion (due to flames produced
by the ignited primer) produces enough pressure from the produced gases to propel the missile
from the cartridge with violent force towards the target. Two types of powders are used in firearm
ammunition viz., black powder and smokeless powder.
Black powder: is rarely used now as it produces lots of black gas resulting in soiling of the
firearm and the hands of the person firing the gun. It contains potassium nitrate, sulphur and
charcoal.
Smokeless powder: is not completely smokeless although the amount of gas produced is
small and is not black, so it does not soil the firearm and the assailant’s hand. It is frequently
used in modern firearm ammunition. It may be ‘single based’ when it contains nitrocellulose
as the main ingredient and ‘double based’ when contains nitrocellulose and nitroglycerine as
the principle ingredients.
5. Wadding: is a piece of either plastic, fiber or felt which is housed between the powder and
the shots (thus it is present only in shotguns, see figure 4). Wad prevents escaping of gases and
acts as piston to push the shots out of the cartridge case. Although not a projectile by themselves,
the wads may travel up to some distance from the firearm, thus may act as helpful material for
forensic evidence in establishing the position of the assailant and at times the type and make of
weapon as some manufacturer imprint the wad with their symbol and encrypt the size of shot
contained in that cartridge.

What is ballistics?
The study of motion of a projectile with regards to a firearm is called ballistics. It has three parts

1. Internal ballistics: The study of motion of projectile inside the barrel of the gun. Ballistic
experts deal with internal ballistics.
2. External ballistics: The study of motion of the projectile after it leaves the barrel and before it
hits the target. This too comes in purview of the ballistic experts.
3. Terminal ballistics: also called wound ballistics is the study of projectile’s impact on the
tissues. This comes in domain of the doctor treating a patient with a firearm injury or in case of
death, a forensic expert. As a doctor is the first person to evaluate the wounds of a person injured
by a firearm, it is his responsibility to record the wound precisely so as to help the law enforcing
personnel in investigating the crime. Any callousness in recording the wound may seriously
jeopardize the vital forensic evidence.

Let us now focus on to the various patterns of injury a firearm can produce.

Gunshot injury patterns

A projectile (bullet or shots) fired from a gun may produce a variety of wounds. A firearm projectile
crushes the tissues that come in its path thus creating a hole along the path it traverses, producing a
‘permanent cavity’. This is unlike a stab wound where the tissues retract to their normal position once
the weapon is withdrawn from the body. In addition, the kinetic energy of the bullet may also generate
shockwaves while traversing through the body and injure the tissues that does not even come in its
contact (this mechanism of injury is called ‘temporary cavitation’).

A gunshot wound may also show other characteristics on the victim such as impression of the muzzle
in case the barrel of the gun was held tightly against the body, the unmistakable appearance of the
products of combustion like that of flame, the smoke produced and that of unburnt powder around the
gunshot wound which are not present in wounds produced by any other weapon. However, a number
of factors such as the type of firearm and ammunition used, the distance from which the shot is fired
and the presence of clothing on the site of wound, affect the appearance of gunshot wounds so one
should be aware of these morphologic deviations of the gunshot wound.

When a gun is fired the projectile is released along with flame, smoke and the partially burnt
gunpowder. They cause following impressions/ damage to body:

1. Flame: the flame emanating from the gun may cause burning of the skin (superficial burn) and
singeing of the hairs in the region. The distance to which the flame can emanate from a firearm is
limited approximately to 30 cms, so burning/ singeing is not usually seen when the gun is fired
from more than 30 cms on an average. The presence of thick clothing at the site of gunshot may
guard the skin from burning/ singeing.
2. Smoke: produced may be deposited on the skin and appear as blackened area over the skin
(known as blackening) that may easily be wiped off by a damp cloth. The blackening may be less
or even absent in case where smokeless powder is used in the ammunition. Again the presence
of clothes at the site may prevent blackening. Like flame, the smoke can also travel to a maximum
of 30 cms, so beyond this distance blackening is not usually seen.
3. Gun powder residue: The partially burnt or unburnt gun powder thrown out from the
cartridge may get embedded in the skin and produce a characteristic stippled appearance on the
skin known as ‘tattooing’. As in the tattoos which are made for style statements, the ink is
deposited subdermally so that it cannot be removed by washing or wiping, similarly the deposition
of gunpowder residue in a firearm wound is subdermal so it also cannot be removed by wiping or
cleaning the wound. The average distance up to which the gun powder residue can travel is
approximately 45 cms so tattooing is not usually seen beyond this distance. Like singeing and
blackening the presence of thick clothing at the site may prevent tattooing.
4. Wad: In case of a shotgun, the wads contained in the cartridge may be driven to some
distance inside the wound when the gun is fired at a distance of less than 2 meters. Beyond this
distance the wads lose enough of their kinetic energy to penetrate the skin.
5. Entry wound of the projectile: The projectile when strikes the body, indents the skin,
stretches it inwards and then perforates it at the centre of maximum stretch. After the projectile
enters the body the skin recoils back and comes to its original position due to its elasticity. During
entry of the projectile into skin, the skin around this point of entry gets violently rubbed against the
projectile producing a rim of abrasion around the entry wound known as abrasion collar.
At times, the debris, oil or grease from barrel of the gun may be deposited around the wound of
entry which appease as a black rim just outside the abrasion collar and is known as dirt/ grease
collar.
The wound of entry may be circular when the entry of the projectile is at right angles to the skin,
however the shape may be elliptical once the projectile enters at an angle to the skin. The
margins of the wound may be sharply defined and are inverted. However, at places where the
elasticity of the tissues at the site of entry is less or there is underlying bone, the wound may have
irregular margins and thus may appear lacerated. The size of the wound of entry may not
corroborate with the size of projectile. Because of the elasticity of the skin, the size of the wound
of entry may be smaller than the size of the projectile or at places where it lacerates the skin and
underlying tissues, the size may be larger than the size of projectile.
The above description holds true for wounds produced by bullets and shotgun wounds when fired
from a close range (usually less than 2 meters where the all the shots contained in the cartridge
enter the skin as a single mass). Beyond approximately 2 meters the pellets/shots of the shotgun
cartridge starts dispersing and there are satellite entry wounds of individual shots in addition to a
main entry wound from where most of the undispersed shots enter the body. The main wound
progressively becomes smaller with the increase in distance from the gun and the point of entry,
such that beyond 6 meters the main wound is not usually seen and only multiple entry wounds
produced by individual shots is seen distributed over a large area on the body.
6. The wound of exit: This is seen only where the projectile has sufficient kinetic energy and
comes out through the body without getting lodged inside. Unlike the wound of entry, the size of
this wound is usually larger, the margins everted and irregular and is conspicuous by the absence
of the effect of flame (burning/ singeing), smoke (blackening) and gunpowder (tattoing).
7. Grazed or gutter wound: When
a bullet strikes the skin tangentially,
 it may not enter the body instead it forms a track damaging the skin and subcutaneous tissues
such that the entry and exit wounds are joined together (Figure 5). However the wound may still
show other features of gunshot wound like singeing, blackening and tattooing.

How to record a gunshot wound?

Now when you know the various characteristics a gunshot wound may have, these should be looked
for diligently and recorded at the first sight. This does not mean that recording the injury should take
precedence over the resuscitation of the gunshot victim, but one may have the mental impression of
the wound (you may also take a photograph) and as soon as the initial assessment and management
of the patient is completed, record the injuries. This is of paramount importance as the wound may
change in appearance during management. For instance, the soot may get wiped off while cleaning
and the wound may change in size and shape once it is enlarged for securing hemostasis or for
debridement. This may destroy the vital forensic evidence which may be of much help in identifying
the type of firearm used and estimating the distance and direction of the fire.

As soon as you encounter a patient of gunshot injury, police needs to be informed and the case is
registered as medico-legal. A short, relevant history should be taken (from the patient, if possible or
from the accompanying persons) that should include the time and place of assault, the approximate
distance of fire, number of assailants, number of shots fired and type of firearm used. You may not be
able to obtain all these parameters but record whatever you can gather. Start writing with the date and
time of your assessment and always begin by using the words ‘Alleged history of’. If you are not using
these words, it may be inferred from the records that you are confirming what the patient or the
accompanying person is saying and you know that you can never be sure of the facts. Following
history you should record the brief general evaluation of the patient based on ATLS protocols (see
later).

The state of clothes should be seen and recorded. Clothing should be carefully removed by cutting
through the areas not affected by the gunshot and submitted to the police. In addition, any soot
present around the site of wound should be wiped by a dry swab, loose foreign material like pellets,
wad or bullet are collected in suitable containers, duly labeled and are submitted to the Police
personnel. This should be recorded in your notes. You must also record the name and the
identification number (DD number) of the Police personnel to whom you submitted these articles.

Then follows the written description of the gunshot wound. As described above, a firearm wound can
be of three types - Entry wound, exit wound and gutter/ grazed wound. These wounds have
previously been described under the heading ‘firearm injury patterns’. The shape, size, margins of the
wound should be recorded in detail. You may draw a diagram to make the things clear. The presence
of dirt collar, abrasion collar, blackening and tattooing must be mentioned, if present. These are the
characteristic features of a gunshot entry wound and in no other mechanical injuries these features
are present. Failure to record these features may land the medical expert in trouble and may also
jeopardize the forensic investigations.

I recall a case where in court the prosecutor denied a wound to be caused by a firearm as the wound
was described as a ‘lacerated’ one with no description of blackening, singeing or tattooing although in
the history which was recorded by the same doctor the wound was mentioned to be caused by a
firearm.

At times it may be difficult to differentiate between the wound of entry and that of exit, for example
depending on the velocity of the projectile and the distance of fire the size of entry wound may be
smaller, equal or larger than the exit wound. You need not worry; record the characteristics of wound
carefully without labeling them the wound as that of entry or exit. The matter should be left for further
investigations by forensic ballistic experts. There is a word of caution here- if blackening, singeing or
tattooing is absent on an area which is usually clothed you must inspect the clothing of the individual
over that area and record the findings of the state of clothing.

Although you may be able to derive the approximate distance of fire from the wound characteristics
but it may vary considerably depend on the type of gun and ammunition used (this becomes more
complex when country made weapons are used for assault that do not follow the estimated range
applied to standard firearms). It is better to refrain yourself on commenting on the estimated range of
fire during the initial assessment of wound in your records. In fact this is not required and is best left to
the ballistic expert to determine.

There is no single characteristic of wound that is indicative of the manner of sustaining the injury
whether suicide, homicide or accidental. Determining the nature of assault requires multiple pieces of
evidence which includes interviewing the victim and other witnesses, the nature of wounds,
examination of gunshot residue and other ballistic investigations. You should not comment on this in
your initial records and leave the same for further investigations. Saying this, I must emphasize that
your records depicting the alleged history and carefully mentioned wound characteristics will help the
forensic investigations immensely that will help determine the exact nature of assault.

Mode of death following gunshot injury

The projectile from a firearm crushes and directly damages the tissues while traversing through the
body, creating a permanent cavity. In addition, the high kinetic energy of the projectile generates
shock waves that may injure the tissues around the permanent cavity to a variable distance. The
organs which come in the way of projectile and shock waves are damaged (lacerated by crushing
effect and contused or ruptured by shock waves) with varying consequence.
Denser a tissue is, greater is the damage by the projectile. Elastic tissues suffer less damage. Thus,
lung tissue of low density and high elasticity is damaged much less as compared to muscles which
have higher density and some elasticity when subjected to the same momentum of the projectile.
Solid visceral organs like liver, spleen and brain have little tensile strength and elasticity and are
easily crushed. Fluid-filled organs like urinary bladder, heart, great vessels and bowel can rupture
because of shock waves generated by the projectile. A bullet when strikes a bone may cause
fragmentation of bone or at times of bullet itself. These fragments of the bone or that of bullet move
further with high speed due to momentum of the projectile and themselves may act as secondary
missiles, each having potential for additional damage.
Immediate death occurs if vital organs like brain and heart are damaged. The torn large vessels like
aorta and vena cava cause sudden exsanguination and death. Other medium or small caliber vessels
like those of mesentery and those supplying the organs like liver, spleen, kidney, liver and extremities
may bleed significantly and can give rise to hemorrhagic shock and death. Injury to gut will cause
peritonitis with its dreaded consequences. The death following gunshot injury is preventable to a large
extent and the key lie in early recognition of injuries and their aggressive management.

Principles of management of a gunshot victim

The principles of managing a patient with gunshot injuries are same as that of any other patient of
trauma. The first and foremost thing needs to be evaluated is to recognize what is killing the patient.
The specific diagnosis as to which organ is injured may be difficult to make and is not at all required
during initial evaluation and resuscitation of a gunshot victim.

The philosophy of ATLS

It has now been well recognized that the Advanced Trauma Life Support (ATLS) protocol is one safe
and effective way of managing a trauma victim. Various studies conducted all across the globe have
proved the efficacy in saving the life of a trauma victim when ATLS protocols are applied. 4 The ‘Initial
assessment’ of a trauma patient as per ATLS protocol focuses on to identify what is killing the patient
and simultaneous correction of same. This has been described by ‘ABCDE’ that stands for Airway
(with cervical spine control), Breathing (with ventilation), Circulation (with hemorrhage control),
Disability (neurologic disability) and Exposure (with environment control). This suggests the priority of
evaluation and correction of the patient’s airway over evaluation and correction of the ‘breathing
problem’ which takes precedence over the assessment and the control of hemorrhage and so forth.
This makes sense as a blocked airway will kill the patient faster than a hemo or pneumothorax which
will kill the patient faster than bleeding and a closed head injury.

Primary management
The evaluation and resuscitation of the patient goes hand in hand. No time is spared in completing
the medico-legal formalities. As soon as you come across a patient with gunshot injury look for
ABCDE and manage them simultaneously. This may require tracheal intubation or surgical
cricothyroidotomy for securing the airway, putting in a needle to drain a tension pneumothorax or an
intercostal chest tube to drain hemo or pneumothorax. A hemodynamically stable patient may be
safely observed initially. If there is any bleeding from the surface, direct pressure should be applied
which is effective most of the times in controlling the hemorrhage. With any evidence of bleeding
inside the abdomen (a patient with a gunshot injury to abdomen who presents with persistent shock
despite adequate fluid resuscitation), urgent laparotomy will be required for controlling the
hemorrhage. Similarly a patient with continued bleeding from the chest tube that makes the patient
hemodynamically unstable or the one who requires continuous infusion of fluids, blood and blood
products to maintain the hemodynamics will require thoracotomy for control of bleeding. The presence
of peritonitis is again an indication of laparotomy.

To conclude

 Patient with an extremity wound with hemorrhage requires hemorrhage control which may
require application of external pressure or exploration of missile tract. Following hemorrhage
control, the wound may require debridement and any associated vascular or neural injury is
treated accordingly.
 For continued bleeding inside a cavity (Thorax or abdomen) urgent exploration (Thoracotomy
or laparotomy) is warranted.
 The presence of peritonitis mandates laparotomy.
 The specific organs injured are managed in the same way as they are managed following
damage by other mechanisms.

Although abdominal gunshot wounds may be observed and a selective non surgical approach may be
successful in a subset of such patients (like in abdominal stab wounds) but the chances of failure of
non-operative management of gunshot wounds is higher as the extent of damage to surrounding
tissues may be much more than anticipated due to the damage produced by the shock waves.

Management of gunshot wound

The gunshot wounds of the extremity require a thorough evaluation. Such wounds may injure bone,
muscles, vessels or nerves. Frequent evaluation is the rule and helps in minimizing the incidence of
missed neural and vascular damage. Although we are discussing the injury to each of these
structures separately, they may be injured together in a patient.
Fracture will be apparent and is managed by early fixation (internal or external) with debridement of
devitalized and dead soft tissue and thorough lavage of the wound. I emphasize here again that these
fixation methods should be considered in a patient with isolated limb injury only. In presence of other
life threatening injuries, the fractured limb should simply be splinted and is taken care of once the
patient is stabilized and there is no imminent danger to life. The help of an orthopedic colleague is
indispensable.
The limb should be carefully examined for any neural or vascular deficit. In a hemodynamically stable
patient, clinical evidence of nerve injury calls for an early exploration of the wound once other
associated injuries have been addressed. The damaged nerve should be exposed and is repaired
primarily. However in presence of a segmental loss of nerve or wound contamination, the ends of the
nerve should be marked by long silk sutures and the nerve should be repaired at a later date.

Absent or diminished pulsation in an extremity with obvious signs of ischemia distal to the wound
suggests an arterial injury. However, this may also occur with a venous injury once a hematoma or
edema develops in an osteo-fascial compartment and compresses the accompanying artery. These
signs of vascular impairment mandate the exploration of the wound in its entire extent and repair of
vascular injuries. In patients with combined arterial and venous injuries, associated fracture or where
the injury is more than 6 hours old, a fasciotomy should be done as these factors are associated with
a high risk of development of compartment syndrome.5-7 In some patients however, these hard signs
of vascular injury may be absent. Such patients may be subjected to further investigations like duplex
5,8
ultrasonography, CT or MR angiography.

In patients with no vascular or neural injury, the wound should be thoroughly examined for presence
of foreign material like patients own clothing, loose wad or projectile (bullet or pellets). These should
be removed and are preserved for forensic investigations. Any dead and devitalized tissue should be
excised and the wound should be thoroughly irrigated by copious amount of warm saline solution.
There is no need to irrigate the wound with antibiotic solution. Also there is no need to remove the
projectile unless it comes in the wound during its management or it is lodged in a structure which
needs exploration and repair for eg. a projectile lodged in a major vessel. The wound should not be
closed primarily. They can be allowed to heal by secondary intention or may be closed by delayed
primary suturing. With simple punctures and no apparent tissue disruption no debridement or wound
exploration is needed. Such wounds require simple cleaning and dressing. A gunshot wound is not
sterile and a brief course of oral or intravenous antibiotics lasting for 3 to 7 days is required.

With injury from high velocity projectiles (like the one fired from a rifled weapon), there is a possibility
of injury to surrounding structures adjacent to the tract of the projectile due to shock waves. Provided
neural and vascular injuries are excluded, such injuries can safely be managed by local debridement,
wound toilet and administration of systemic antibiotics. There is no need for extensive wound
exploration in such patients. Although few studies recommend routine evaluation of such wounds by
MRI scan,9,10 this should be reserved for a small number of patients having complex wounds with long
tracts in which the clinical evaluation of the wound may not be accurate.

Some interesting myths about gunshot injuries

1. In movies, you must have seen the gunshot victim being thrown backwards when struck with
the bullet. In fact, a person can never get displaced because of the momentum of the bullet.
The maximum momentum that can be transferred from projectile to an individual weighing 80
kg is only 0.01 to 0.18 m/s, which is negligible as compared to the 1 to 2 m/s velocity of a
pedestrian. The incapacitation of a gunshot victim primarily depends on the area of the body
injured. Immediate incapacitation may occur with gunshot wounds to the brain and upper
cervical cord. Rapid incapacitation may occur with massive bleeding from major blood vessels
or the heart.
2. Contrary to the popular belief and the known possession of heat in the fired projectile, the
bullet wounds are not sterile. The bullet may be contaminated by the oil/ grease used in gun
barrels for lubrication. In addition, the bullet may carry the bacteria on the skin and clothing of
the victim into the track of the wound. Also, the pressure difference between atmosphere and
the wound cavity drives air to sweep debris inward into the track of the wound leading to
wound contamination. Because of all this gunshot wounds are prone to infection like any
other wound.
3. It is commonly seen in Hindi cinemas (and this is also a popular belief in the general public)
that the bullet lodged in the body of a gunshot victim requires retrieval. This is far from truth.
Although retrieval of a lodged bullet will be of great asset for forensic investigations, it does
not require retrieval just for investigative purposes. Wherever the attempts to retrieve a
lodged bullet may pose additional risk to the life or limb of the patient, the bullet can be safely
 left in the body. A retained bullet rarely causes a problem. It is retrieved only if it is easily
recoverable during exploration of the wound in extremity or a body cavity or else if the lodged
bullet poses a threat to life or limb of a patient, for example the one lodged in a heart, major
vessel, orbit or a joint cavity.

Suggested readings
th
1. Lyon’s Medical Jurisprudence & Toxicology. TD Dogra, Abhijeet Rudra. 11 Ed 2005. Publisher- Delhi Law House.
th
2. Advanced Trauma Life Support for Doctors (ATLS) Student Course manual. 9 Ed 2012. American College of
Surgeons Committee on Trauma.
REFERENCES

1. Kohli, A, Karp A, Marwah S.’Mapping Murder: The Geography of Indian Firearm Fatalities IAVA Issue Brief No. 2;
p. 1. New Delhi: India Armed Violence Assessment / IAVA and the Small Arms Survey (Geneva);2011.
2. Gunpolicy.org [Internet]. India-gun facts, figures and the law. Accessed Sep 2013. Available from:
http://www.gunpolicy.org/firearms/regions/india.
3. Crime in India 2012. Accessed Sep 2013. Available from: http://www.ncrb.gov.in.
th
4. Course overview. In: ATLS student course manual 9 edition 2012. American college of surgeons committee on
trauma. p. xxiii-xxx.
5. Waes O, Lieshout E, Hogendoorn W, Halm JE, Waes J et al. Treatment of penetrating trauma of the extremities:
ten years’ experience at a dutch level 1 trauma center. Scand J Trauma Resusc Emerg Med. 2013 Jan 14;21:2.
doi: 10.1186/1757-7241-21-2.
6. Branco BC, Inaba K, Barmparas G, Schnüriger B, Lustenberger T, Talving P et al. Incidence and predictors for the
need for fasciotomy after extremity trauma: a 10-year review in a mature level I trauma centre.
Injury. 2011;42:1157-63.
7. Berg RJ, Okoye O, Inaba K, Konstantinidis A, Branco B, Meisel Ec et al. Extremity firearm trauma: the impact of
injury pattern on clinical outcomes. Am Surg. 2012;78:1383-7.
8. Burg A, Nachum G, Salai M, Haviv B, Heller S, Velkes S et al. Treating Civilian Gunshot Wounds to the Extremities
in a Level 1 Trauma Center: Our Experience and Recommendations. IMAJ.2009;11:546-51.
9. Parker SJ, Jarvis LJ, Dale RF. Magnetic resonance imaging in the evaluation of a high-velocity gunshot wound to
the thigh. Br J Surg. 1997;84:11-19.
10. Hess U, Harms J, Schneider A, Schleef M, Ganter C, Hannig C. Assessment of gunshot bullet injuries with the use
of magnetic resonance imaging. J Trauma. 2000;49:704-9.

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