Firearm Injuries: A Review of Wound Ballistics and Related Emergency Management Considerations

Gunshot injuries are challenging conditions because of the unique characteristics of the wounding agents producing soft tissue damage that may be compounded by the formation of an expanding temporary cavity (cavitation). Variations in ballistic performance leading to higher energy transfer by the projectile, including bullet tumbling, deformation, and fragmentation, cause increased soft tissue injury and may also lead to more extensive bone comminution compromising local blood supply. Once life-threatening injuries have been excluded or properly addressed, the emergency management of localized trauma from bullets and shotgun pellets may be complicated due to progressive tissue necrosis within the zone of injury. Additionally, the risk of infection should be tackled, especially in high energy bone injuries. War experience suggests a baseline separation between wounds with limited tissue destruction which can routinely be managed as simple penetrating injuries and those resulting from high energy transfer to the tissues involving a substantial amount of necrotic elements surrounding the wound channel which call for a more aggressive surgical approach. A further justification for such a distinction is the need for antibiotic therapy, which varies according to most studies depending on the wounding mechanism, the nature of the wound, and the extent of tissue injury. The emergency physician should also be aware of the possibility of “bizarre” bullet paths resulting in occult injuries of important anatomic structures.