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According to a CDC report, the majority of gun-related deaths in the United States are suicides, with 17,352 (55.6%) of the total 31,224 firearm-related deaths in 2007 due to suicide, while 12,632 (40.5%) were homicide deaths (Jiaquan, Kochanek, Murphy, & Tejada-Vera, 2010). Other gun-related deaths were accidental, by legal intervention, and undetermined. Children are frequent victims of violent crime. Gunshot wound is a high-velocity penetration of the body by a bullet, commonly marked by a small entrance wound and a larger exit wound; usually accompanied by damage to blood vessels, bones, and other tissues. The exposure of the wound to the external environment and debris carried inside the body by the bullet, may result in a high risk of infection. Additional complications depend on the part of the body wounded, the type and caliber of weapon used, as well as at what distance and angle the victim was shot. Because violence is often associated with the use of alcohol and other drugs, treatment of these patients may be complicated by the effects of these drugs. Shootings in both schools and workplaces have become more common and more deadly. Keep alert and always report suspicious incidents to the authorities. Drug-related murders in Mexico have yield to many lives and the violence is likely to worsen.
Bombs and explosions at accidents, bank robbery, gang warfare, and terrorist attacks can cause unique patterns of injury seldom seen outside combat. Explosions can inflict multi-system life-threatening penetrating and blunt injuries to many persons simultaneously. Multiple factors contribute to the injury pattern which results from blasts including the composition and amount of the material involved, the environment in which the event occurs, the method of delivery (bomb), the distance between the victim and the blast, and protective barriers and environmental hazards in the area of the blast. Explosions in confined places, such as buildings, large vehicles, mines, and structural collapse are associated with greater morbidity and mortality. A person in the path of an explosion will be subjected not only to excess barometric pressure, but to pressure from the high-velocity wind travelling directly behind the shock front of the blast wave. People between the blast and a confined area or walls (building) generally suffer two or three times the degree of injury compared to those in open spaces.
It is useful to remember that post-blast, half of all the initial casualties will seek medical care over the first one-hour period. Most severely injured arrive after the less injured, who go directly to the closest hospital using whatever transportation is available (American Public Health Association, 2005, 1). The two types of explosives, loworder explosives (LE) and high-order explosives (HE), cause different injury patterns. LE devices, such as pipe bombs, gunpowder, and pure petroleum-based bombs create a subsonic explosion and lack the over-pressurization wave, while HE devices, such as TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil, produce a defining supersonic over-pressurization shock wave. Manufactured or improvised bombs also cause different injury patterns. Manufactured explosions are usually those used by the military, are mass produced, and quality tested as weapons, whereas improvised explosives and fire bombs are individually produced in small quantities and include devices used differently than their initial purposes. All blast injuries have the potential for chemical and/or radiological contamination.
To reduce the number of fatalities during the critical first few minutes, emergency medicine can now be provided deep inside enemy territory. All soldiers on operation have basic first aid training, and one in four soldiers is an army team medic. They have advanced first aid training and carry additional medical equipment including products to stem excessive bleeding, such as the HemCon bandage. It contains a substance derived from crushed shellfish, becomes sticky on contact with blood, helping clots develop and rapidly stopping even severe bleeding (NHS choices, 2009).
Penetrating (sharp) injuries: include stab wounds and incised wounds from penetration or cuts, but not lacerations. Sharp force injuries (stab wounds) tend to be deep rather than long. Incisions tend to be long rather than deep. Sharp force injuries have generally a clear appearance.
Blunt injuries: Include lacerations (only from blunt force impact), abrasions, contusions, and fractures. Blunt force injuries usually results from assaults, abuse, accidents, or resuscitative interventions. Lacerations are characterized by rough edges marginal abrasions, and bridging by nerves and vessels.
Dicing injuries: consist of multiple, minute cuts and lacerations caused by contact with shattering tempered glass from the vehicle’s windows.
Patterned injuries, the specific characteristics of patterned injury reflect the identity of the wounding object or provide information about the nature of the weapon.
Defense wounds, indicate the posture of a victim in protection against attack, can be either penetrating or blunt, depending upon the weapon used.
Fast force injuries, usually gunshot, different kinds of guns give various pattern of injury. Gunshot wounds are generally more serious, but frequently leave an entry and exit wound that allow assessment of probable structural damage. Low-velocity penetration of the body by a bullet is commonly marked by small equal-sized entrance- and exit wounds, whereas high-velocity penetration by a bullet is commonly marked by a small entrance wound and a larger, often star-shaped exit wound.
Blast injuries, bombs and explosions can inflict multi-system life-threatening injuries. Predominant injuries involve multiple penetrating injuries and blunt trauma to any body system. Explosions in mines, buildings, or large vehicles and structural collapse are associated with the greatest morbidity and mortality. Blast lung is the most common fatal (penetrating) injury among initial survivors.
Follow the standard ABC plan, and evaluate the airway, breathing, and circulation. Take in the scene and continue to gather information while assessing the injured victim. Try to obtain information from bystanders, if possible. Accurate assessment at the scene can provide vital clues to the nature of the victim’s injuries. The specific information will be valuable to you and the treating physician. If wound is to the torso, neck or legs, have a rescue team remove the victim on a stretcher to a safe zone.
In penetrating injury (gunshot wounds) important information includes the following:
Ballistics is the study of the dynamics (the motion, trajectory and impact) of bullets in gunshot and rocket injuries. Documents, gathering, and preserving evidence are a serious cause of concern in traumatic injury patients. The emergency staff is often the first persons to observe the types of trauma on a patient. Violent, sudden and unexpected deaths that occur because of trauma or unknown cause require investigation, and evidence must be retained. Preservation of evidence and careful documentation of the previous history, the appearance of the victim on arrival at the hospital, and circumstances surrounding the death may clarify important points, and serve as a vital link between the victim, medical examiner and police. An autopsy is generally performed. Another difficult issue is to oversee organ donations because most donors are young, healthy people who die as the result of trauma.
The immediate damaging effects of the bullet are bleeding, and the potential of hypovolemic shock. The heart, brain or spine is especially vulnerable to injury. Common causes of death following gunshot injury include exsanguinations, hypoxia caused by pneumothorax, heart failure and brain damage. Non-fatal gunshot wounds can result in disfigurement and permanent disability (spinal injury). A bullet that penetrates the brain must enter through the skull; bone fragments may be driven into the wound along with the foreign object, causing additional injury to the brain. Intracranial bleeding and structural damage may result. Penetrating injury usually fractures the skull, and the bullet may be retained in the brain. Firearms cause a substantial proportion of all traumatic spinal injuries. Penetrating thoracic or abdominal injuries can lead to impalement, laceration, or rupture and puncture of the thoracic or abdominal organs, all of which can cause loss of both structure and function. Gunshot wounds to the chest are associated with significant morbidity and mortality because of injuries to intrathoracic structures, including the heart, major vessels, lungs, tracheobronchial tree, esophageal and spinal cord. Gunshot wounds are serious, as bullets shatter organs and spill intestinal contents in the abdominal cavity. The entry and exit wound allow the health care provider to assess probable structural damage and plan interventions accordingly. Gunshot wounds to prostate gland and seminal vesicles are rare. Penetration of the pregnant uterus by a bullet exposes the fetus to direct injury by contact with the object or indirect as a result of maternal injury. Penetrating injury in infants and children is usually due to assault (gunshot wounds) or accidents (impalement). Adolescents are frequent victims of violent crime.
Any body part may be affected by blasts. Typical head injuries associated with an explosion can be a closed impact to the head, which causes bleeding in the head, such as an epidural hematoma or subdural hematoma. The blow to the head can fracture the skull. If the blast crushes the skull and lacerate the scalp, metal or shrapnel can be driven into the brain. The sheer force of the explosion can also cause swelling and pressure. In addition, when shrapnel or any foreign object is driven into the brain, it can lead to a secondary infection of the brain, a brain abscess or meningitis. Weeks to months after a shrapnel injury to the brain, epileptic seizures can develop. Blast lung is a severe pulmonary contusion, bleeding or swelling with damage to alveoli and blood vessels can occur. It is reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head and torso; usually present signs at time of initial evaluation, but may be delayed up to 48 hours. Suspect blast lung in anyone with dyspnea, cough, hemoptysis, or chest pain following blast. Chest X-ray shows “butterfly” pattern. It is the most common cause of death among initial survivors. Bleeding from injured organs such as lungs and gastrointestinal tract causes a lack of oxygen delivered to the brain. Amputations are common with explosions. Patients exposed to blast injury may manifest headache, confusion, loss of memory for events before and after explosion, impaired sense of reality, and reduced decision-making ability. Up to 10 percent of all blast survivors have significant eye injuries (American Public Health Association, 2005, 1).
Blast injury can be categorized by four basic mechanisms (American Public Health Association, 2005, 1; CDC-Blast Injuries, 2008):
In children a traumatic brain injury can occur without the patient losing consciousness; look for other signs of head or neurological injuries. Suspect cervical spine injury in children with head injuries. Traumatic asphyxia may occur in children. Chest injuries by blunt force impact, are a common cause of death in children subjected to blast injury. Children have a shorter trachea than adults and endotracheal intubation is more difficult. Always suspect tension pneumothorax in the hypotensive, hypoxic child. Children are more prone to abdominal injuries because of many anatomical differences from adults, and the spleen and liver are the organs most vulnerable to blast injury. Fractures are common in children (such as greenstick fractures). Children are also more susceptible to heat loss.
The elderly have an increased risk of fractures (skull, ribs, flail chest, hip) and traumatic brain injury. Co-morbid conditions, physiologic reserve, multiple concurrent injuries, along with the medications used for them, need to be taken in account when managing the care of older blast victims. Physiologic derangements in the elderly can be occult, as well as physiologic responses to hypovolemia (tachycardia, hypotension). Decreased hearing and visual impairment are common in the elderly, and delirium (may be due to medications).
The primary goals are to preserve the injured victims’ lives and transfer them to an emergency facility for the best possible outcomes; and also to provide emotional support for everyone involved; victims, close ones, bystanders and responders. In general, time is not spent at the scene to intubate or securing intravenous access, unless it is deemed essential. Your interventions should be within the scope of your professional license, skills and training, and when performed in a health care setting, adherent to the facility’s standard of practice. Assess and reassess the patient regularly.