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gun·shot wound (GSW),
gun·shot wound(GSW) (gŭn'shot wūnd)
|Mean LOS:||5.3 days|
|Description:||MEDICAL: Other Respiratory System Diagnoses With Major CC|
|Mean LOS:||10 days|
|Description:||SURGICAL: Major Cardiovascular Procedures With Major CC or Thoracic Aortic Aneurysm Repair|
|Mean LOS:||15.2 days|
|Description:||SURGICAL: Pancreas, Liver, and Shunt Procedures With Major CC|
|Mean LOS:||12.7 days|
|Description:||SURGICAL: Splenectomy With Major CC|
|Mean LOS:||9.1 days|
|Description:||SURGICAL: Other Operating Room Procedures for Multiple Significant Trauma With CC|
Penetrating trauma from a gunshot wound (GSW) or firearm injury can cause devastating injuries. The most commonly injured organs and tissues are the intestines, liver, vascular structures, spleen, and intrathoracic structures. Evaluating injuries is difficult; it is important to determine the type of weapon, energy dissipated from the weapon, firing range of the weapon at the time of injury, and characteristics of the injured tissue. GSWs can lead to the need for extensive débridement, resection, or amputation. Among the many complications are sepsis, exsanguination, and death.
In the United States, GSWs account for approximately 32,000 deaths a year. Approximately 61% of gun deaths are suicides, 34% are homicides, and the rest are from other causes, primarily an unintentional death. The United States has 4% of the world’s population, but possesses 50% of the world’s privately owned firearms. GSWs can be perforating, when the bullet exits the body, or penetrating, when the bullet is retained in the body.
The energy of the missile is dissipated into tissues of the body, causing destruction of vital and nonvital structures. When the missile enters the body, it creates a temporary cavity, which stretches, distorts, and compresses the surrounding anatomic structures. The cavity that is produced often has a greater diameter than the missile itself. In a situation called “blast effect” or “muzzle blast,” damage occurs in structures outside the direct path of the missile. High-velocity missiles (bullets from shotguns, rifles, or high-caliber handguns) cause extensive cavitation and significant tissue destruction, while low-velocity missiles (bullets from low-caliber handguns) have limited cavitation potential with less tissue destruction. Another characteristic of missiles is the yaw, which is the amount of tumbling and movement of the nose of the missile that occurs. The more yaw, the greater the tissue damage.
Gender, ethnic/racial, and life span considerations
Penetrating injuries are on the increase across all ages of the life span, particularly among adolescents and young adults in their teens and 20s. GSWs are more common in males than in females. African American males ages 15 to 24 have the highest homicide rate from GSWs in the United States, followed by Hispanic males. Suicide rates are highest among Native American males and non-Hispanic white males.
Global health considerations
Nations with high levels of civil strife, political instability, or at war have a high prevalence of GSW death and disability. South Africa, Brazil, Columbia, El Salvador, Guatemala, Honduras, and Jamaica have high rates of gun-related deaths as compared to other countries.
Establish a history of the weapon, including the type, caliber, and range at which it was fired. Determine if the GSW was self-inflicted as well as the patient’s hand dominance and tetanus immunization history.
The most common symptom is an open puncture wound from the bullet and bleeding. The initial evaluation is always focused on assessing the airway, breathing, circulation, disability (neurological status), and exposure (completely undressing the patient), which are done simultaneously by the trauma resuscitation team. The secondary survey is a head-to-toe assessment, including vital signs.
After completing the primary survey, begin the secondary survey with a complete head-to-toe assessment. Examine the patient’s entire skin surface carefully for abrasions, open wounds, powder burns, and hematomas, paying special attention to skin folds, groin, and axillae. Assess the patient’s abdomen, back, and extremities for lacerations, wounds, abrasions, and deformities. Some high-velocity weapons may cause extensive tissue destruction and fractures. Inspect the patient for both entrance and exit wounds (Table 1).
|TYPE OF WOUND||DESCRIPTION||DESCRIPTION OF WOUND||EXPLANATION|
|Entrance: Soft contact||Gun is pressed against skin prior to shooting||Seering of edges of bullet hole, soot or smoke depositions around wound||Hot gases and flame when gun is shot burn edges of wound|
|Entrance: Hard contact||Gun barrel is pressed firmly into skin||Little or no soot on edges of bullet hole; smoke and soot in deep layers of wound||Soot, burning gun powder fragments, smoke, and hot gases are forced to penetrate deep into wound|
|Entrance: Blow back||Hard contact wound of head||Wound is very large, irregular, and gaping||The thin layer of skin and muscle over bones of skull causes a large amount of energy to be forced directly into the wound|
|Entrance: Intermediate range||No contact but within 48 inches||Tattooing: Fragments of gunpowder strike surface of skin and become embedded; Stippling: Fragments of gunpowder strike with enough force to cause abrasions but do not penetrate skin||Pieces of burning gunpowder exit the gun barrel while firing and damage the skin; the closer the muzzle is to skin, the smaller the area of distribution and greater the concentration of fragments around the entrance wound|
|Entrance: Indeterminate range (unable to determine distance)||No contact but more than 48 inches||Bullet hole surrounded by area of abrasion||Size of hole depends on angle of entry, caliber of weapon, layers of clothing, other factors|
|Exit||Same general appearance regardless of range of fire||Configuration of wound varies widely: Irregular, jagged, round, slitlike||Size of bullet does not determine size of wound; small, highly deformed bullet may produce a larger wound than a large bullet|
Perform a thorough fluid volume assessment on at least an hourly basis until the patient is stabilized. This assessment includes hemodynamic, urinary, and central nervous system parameters. Notify the physician of overt bleeding and of any early indications that hemorrhage is continuing; this includes delayed capillary refill, tachycardia, urinary output less than 0.5 mL/kg per hour, and alterations in mental status, including restlessness, agitation, and confusion, as well as decreases in alertness. Body weights are helpful in indicating fluid volume status; note that many of the critical care beds have incorporated bed scales.
The violent and often unexplained nature of this type of trauma can lead to ineffective coping for both the patient and the family. Determine if the patient is at risk from herself or himself or others by questioning the patient, significant others, or police. If the patient is on police hold, determine the patient’s and family’s response to the pending legal charges.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Complete blood count||Red blood cells (RBCs): 4–6.2 million/μL; hemoglobin: 12–18 g/dL; hematocrit: 37–54%; white blood cells: 4,500–11,000/μL; platelets: 150,000–400,000/μL||Decreased values reflective of the degree of hemorrhage||Determines the extent of blood loss; note that it takes 2 hr for hemorrhage to be reflected in a dropping hemoglobin and hematocrit after injury|
|X-rays of areas near the GSW; if head or neck injury is suspected or patient is unconscious, x-rays of chest, pelvis, and lateral cervical spine are needed||No injury in bony structures||Damage to bones and joints in area of wound||If wound is near bony structures, entire surrounding area needs to be assessed for injury|
|Computed tomography scan||No injury to body structures||Damage to organ and supporting structures; collection of blood in tissues, location of foreign bodies (missiles)||May be used to identify abdominal, urological, chest, and head injuries (actual and suspected); injuries to bony structure; trajectory of penetrating missile|
Other Tests: Blood chemistries, angiography, endoscopy, indirect laryngoscopy, arterial blood gases, pulse oximetry, urinalysis, excretory urography
Primary nursing diagnosis
DiagnosisIneffective airway clearance related to airway obstruction secondary to tissue trauma
OutcomesRespiratory status: Ventilation; Respiratory status: Gas exchange; Symptom control behavior; Medication management; Comfort level; Knowledge: Treatment regimen
InterventionsAirway insertion and stabilization; Airway management; Airway suctioning; Anxiety reduction; Artificial airway management; Mechanical ventilation; Oxygen therapy; Positioning; Respiratory monitoring; Surveillance; Ventilation monitoring; Vital signs monitoring
Planning and implementation
Maintaining a patent airway, maintaining oxygenation and ventilation, and supporting the circulation are the first priorities. Assist with endotracheal intubation and mechanical ventilation. Maintain the Pao2 at greater than 100 mm Hg and the Paco2 at 35 to 45 mm Hg. The patient may require placement of a tube thoracostomy to drain blood and relieve a pneumothorax.
Restoring fluid volume status is critical in maximizing tissue perfusion and oxygenation; the use of pressure infusers and rapid volume/warmer infusers for trauma patients requiring massive fluid replacement is essential. Administering warm blood products and crystalloids assists in maintaining normothermia. Be prepared to administer vasopressors after fluid volume status is stabilized. Patients who require massive fluid resuscitation are at risk for developing hypothermia, which exacerbates existing coagulopathy and compounds their hemodynamic instability. Paramount in managing patients is a rapid fluid resuscitation with blood, blood products, colloids, and crystalloids through a large-bore peripheral intravenous catheter or a large-bore trauma catheter.
Patients frequently require surgical exploration to identify specific injuries and control hemorrhage. After surgical exposure is obtained, any of the following may be required: assessment of structures, control of hemorrhage, débridement, resection, or amputation. If definitive surgical intervention is not possible because of the patient’s instability, a temporizing method known as “damage control” may be instituted. Damage control consists of the placement of packing to achieve a temporary tamponade, correction of coagulopathy, and aggressive management of hypothermia. The patient is then transferred to the critical care unit for continued monitoring and stabilization. The “second look” surgical exploration is generally done in 24 hours for definitive surgical intervention.
|Medication or Drug Class||Dosage||Description||Rationale|
|Antibiotics: Prophylactic antibiotic use is controversial; surgeons follow culture results and institute antibiotics sensitive to the organism that was cultured||Varies with drug||Second-generation cephalosporins or cephamycin||Prevent gram-negative infections when there is traumatic violation of the gastrointestinal tract|
|Low-molecular-weight heparin (enoxaparin, dalteparin)||Varies with drug||Anticoagulant||Prevents thromboembolism during periods of immobility after hemorrhage is controlled; not generally administered in patients with neural injuries|
Other: Many trauma surgeons may choose to administer a tetanus booster to patients with chest trauma whose immunization history indicates a need or whose history is unavailable.
In the emergency phase of treatment, maintain the patient in a supine position unless it is contraindicated because of other injuries. Ensure adequate airway and breathing in this position. Avoid Trendelenburg’s position because it may have negative hemodynamic consequences, increase the risk of aspiration, and interfere with pulmonary excursion. If the patient can tolerate the position, elevate the head of the bed to limit the risk of aspiration and to improve gas exchange.
Wound care varies, depending on the severity of wounds, whether an open fracture is present, and what type of fixation device is applied. Wounds and any exposed soft tissue and bone are covered with wet, sterile saline dressings. Standard Betadine-soaked dressings may not be used because of the need to limit iodine absorption and skin irritation. To decrease the risk of infection of the patient, use a gown, mask, gloves, and hair covers when caring for patients with extensive wounds. Document the size, description, and healing of the wound each day and notify the surgeon if there are signs of wound infection. Use universal precautions in handling all bloody drainage.
If another person has initiated the violence toward the patient, consider assigning him or her a pseudonym for all hospital records to prevent another assault. Do not provide any information about the patient over the phone unless you are sure of the caller’s name and relationship to the patient. If you fear for the patient’s safety, talk to hospital security about strategies to ensure the patient’s safety. If the patient has a self-inflicted injury, make a referral to a clinical nurse specialist or discuss a psychiatric consultation with the surgeon. If the patient is self-destructive, initiate suicide precautions according to unit protocol.
If the patient is being held by police, remember that the patient receives competent and compassionate care even when under arrest. Determine from hospital policy the regulations about visitors if the patient is held by the police. Provide a supportive atmosphere to promote healing of the injury, but use care to avoid being drawn into the legal aspects of the patient’s arrest.
Evidence-Based Practice and Health Policy
Joseph, B., Aziz, H., Pandit, V., Kulvatunyou, N., O'Keeffe, T., Wynne, J., …Rhee, P. (2014). Improving survival rates after civilian gunshot wounds to the brain. Journal of American College of Surgery, 218(1), 58–65.
- Aggressive management of GSWs involving the head may improve survival of what is the most lethal of all firearm injuries.
- In a review of 132 patients who sustained GSWs to the brain, increased management with hyperosmolar therapy and blood products was associated with incremental decreases in mortality from 90% in 2008 to 54% in 2011.
- Although the rate of surgical intervention remained constant across the years at 15% (p = 0.01), craniotomy, hyperosmolar therapy, and blood product administration were independently associated with survival (p = 0.04, p = 0.01, and p = 0.02, respectively).
- The extent of the injury was negatively associated with survival (p = 0.01); however, the pattern of head injury and the Glasgow Coma Scale score at admission did not have significant effects on survival.
- Physical response: Location, size and appearance of wound; description of dressings and drainage on dressings; amount of bleeding from wound; description of accompanying injuries, breath sounds, heart sounds
- Response to treatment: Vital signs, pulse oximetry, urine output, mental status, patency of airway, adequacy of circulation
- Presence of complications: Infection, hemorrhage, organ dysfunction, poor wound healing
- Pain: Location, duration, precipitating factors, response to interventions
- Laboratory results: Electrolytes, measures of organ function, complete blood count, coagulation studies