Field Management of Gunshot Wounds

Some gunshot wounds are almost instantly fatal, some actually require very little, if any, treatment, and still others are borderline for survivability. Whether you spend most of your time in an urban, rural or suburban area, you may one day encounter a gunshot wound victim, particularly if you work in law enforcement or public services such as firefighting and emergency rescue.

The borderline gunshot wounds are the most challenging from a medical perspective. It is often the actions taken at the scene of a shooting that determines the survival of the victim(s).

Wound ballistics

A basic understanding of wound ballistics and emergency medical care procedures are helpful in providing first aid. Additionally, information gathered at the scene and transmitted to the hospital provides the trauma surgeon with the information needed on which to base his initial management of the patient.

Exterior ballistics refers to the actions of projectiles after they leave the barrel of a firearm. For this article, we are not so concerned with what the projectile does in flight through the air, but after impact with the human body. Depending on the individual bullet in each instance, the projectile may tumble erratically or may continue straight and true on its course. It may be deflected by internal structures.

Innumerable factors come together to influence a bullet’s trajectory, and therefore its damage, within a body creating various gunshot wounds. All projectiles, however, share mechanics of damage imparted to tissue.

Gunshots wounds

As the projectile strikes tissue, it compresses and then tears the tissue. This forms what is referred to as the permanent cavity. It is accepted that this tissue is destroyed.

Depending on the action of the projectile, the permanent cavity can be merely a cylinder the diameter of the projectile, or a cavernous space torn from surrounding tissue by the gyrations of the tumbling bullet.

In addition to the permanent cavity, the pressure applied to the tissue surrounding the permanent cavity causes it to rebound away, creating a temporary cavity considerably larger than the permanent cavity. This is an elastic response to force applied. The elasticity of the surrounding tissue determines whether it forms a temporary cavity and returns to position (such as a lung or muscle) or disintegrates and becomes part of the permanent cavity (such as a bone or liver).

The temporary cavity has been documented to oscillate as many as 8 times until the energy is finally dissipated. The kinetic energy of the projectile is carried away from the permanent and temporary cavities in the form of a shock wave that travels in all directions from the wound.

  Related article: Surviving An Active Shooter Scenario

The energy transmitted by this shock wave has been responsible for fracturing bones some distance from the initial wound. Here again, the elasticity of the absorbing tissue determines whether the energy will be passed on further or absorbed, causing damage to the tissue.

A final major consideration of the mechanics of wounding is vacuum. As the permanent and temporary cavities are formed, a vacuum along the projectile’s path, or wound track, is also produced. This vacuum actually pulls debris from the victim’s skin and remnants of his clothes into the wound.

It was once believed that sufficient heat was generated by a bullet in flight to actually sterilize it. This has been disproved many times in the laboratory as well as field environment.

Bullets aren’t sterile, they don’t sterilize the material they strike and drive into the wound, and the material sucked into the wound is also not sterile.

For these reasons, the tissue surrounding the permanent cavity is inoculated with all the microorganisms that were present on any of the materials mentioned above. Gunshot wounds get grossly infected if not properly treated.

Gunshot wounds treatment

Treatment of the gun-shot victim must be considered from two perspectives: pre-hospital care and treatment in the survival situation when isolated from access to a hospital. Initial treatment is the same, in either case.

Primary concerns are air-way management, control of bleeding and treatment of shock.

Airway management

The airway is best managed in the unconscious patient by passing an endotracheal tube and ventilating with a bag-valve assembly (AMBU bag).

If this is not possible, at the minimum an oropharyngeal airway (S-tube, etc.), should be placed in his mouth to keep the tongue from falling back and blocking the airway. If available, oxygen should be administered to the patient. As long as the patient has spontaneous respiration at a rate of greater than 12 per minute, this can be accomplished using a face mask connected to an oxygen source.

Obviously, if the patient stops breathing or his respiratory rate is less than 12 breaths per minute, he will have to be ventilated through an endotracheal tube (attach the Ambu bag to an oxygen source) or by mouth-to-mouth, preferably through a pocket mask which also can be attached to an oxygen source.

Bleeding control

The next concern is to stop any profuse bleeding. This is best handled by applying direct pressure to the wound, if an extremity is wounded, it should be elevated to help achieve this goal. Look for an exit wound.

Be forewarned – exit wounds are not always in a direct line from the entrance wound. Make a diligent search because pressure must be applied here as well. If direct pressure does not seem to suffice, the next step is to locate a proximal arterial pressure point.

Simply stated, this is the point nearest the wound, between the wound and the heart, where a pulse can be felt. Applying pressure on this point with one or two fingers should stop the bleeding.

Important note: Only apply a tourniquet as a last resort.

When you use a tourniquet to control bleeding you have essentially written the limb off as un-salvageable. Mark a large ‘I’ on the patient’s forehead, as well as the time the tourniquet was applied. No pen? Use the patient’s blood.

The next objective in treating gunshot wounds is the prevention or management of shock.

Treatment of shock

Shock is best defined as an inadequate perfusion of the vital organs — brain, heart, kidneys. etc. If these organs do not receive sufficient blood, they will not receive sufficient oxygen and they will be damaged or die.

The body attempts to counter shock by raising the heart rate to over 100 beats per minute. The brain will order the blood vessels near the skin to constrict, thus increasing the blood pressure. This results in cold, wet, clammy skin.

Additionally, because the blood is shunted to the center of the body, the individual will appear to be pale In the latter stages of shock, the body can no longer maintain the blood pressure with these compensatory acts and the blood pressure drops to dangerous levels.

By administering oxygen, the progress of shock is slowed.

Another sign of shock is agitation. The patient may seem to be short-tempered and brusque, when in fact his oxygen-starved brain is the real problem. The blood is what carries oxygen. If the patient continues to lose blood that is not replaced, the shock will ensue regardless of how much oxygen is administered.

The effects of blood loss are countered by elevating the person’s legs about 18 inches. In this position, gravity helps to keep the remaining blood in the area of the vital organs rather than the extremities. If qualified personnel are at hand and the solution available, two intravenous lines should be established using large bore needles or catheters (larger than 18 gauge). Ringer’s Lactate solution should be run as fast as possible.

Squeezing the IV bag by hand or with an inflated sphygmomanometer (blood pressure cuff) facilitates this. No food or drink should be given by mouth. The patient should be kept comfortably warm (not hot) and be reassured until either help arrives or the patient arrives at the hospital.

While no IV fluid is a direct replacement for blood, the solutions will increase the circulating volume and help counteract shock until more definitive measures can be taken.

Gunshot wounds to the chest

One area of wounding that requires special mention is the chest. You may encounter a patient with what appears to be a minor chest wound. Perhaps small caliber, minimal bleeding and walking around.

Within 10 minutes he’s on death’s doorsteps. Any wound of the chest may be an opening into the thorax — the compartment that houses the lungs. As the individual breathes, air can enter that hole as well as the usual route (through the trachea).

This air occupies space, vital space the lung needs in order to do its job. The pressure of the air between the thorax and lung can become so great that it causes the lung to collapse. This is known as pneumothorax.

If the pressure continues to build it can actually push the other organs located in the thorax in the opposite direction. This is known as a tension pneumothorax. The heart is one of the organs found in the thorax. As it is moved to the side, the great vessels that carry blood to and from the heart are kinked, impairing circulation. This constitutes an extreme emergency.

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Without the placement of a chest tube to relieve the pressure, the patient will die. The safest treatment for this, particularly for the layman, is prevention. An occlusive dressing is prepared by placing tape on three edges of a rectangular piece of non-porous material — plastic, cellophane wrap, etc.

If the patient is conscious, have him cough or exhale forcefully.  As he is doing this place the dressing over the wound, taping it tightly to the skin on the three sides. This will now function as a flapper valve, allowing air to escape from the thorax on exhalation, but prohibiting air from entering the wound. By keeping the air from entering the wound, a tension pneumothorax is prevented.

Remember to similarly cover any exit wound, as well. The patient should be transported on the injured side, if possible.

Every five minutes, a complete set of vitals should be taken and recorded, noting the time. Additionally, any time the patient’s condition appears to change, a set of vitals should be taken and recorded. A set of vitals consists of blood pressure, pulse and respiration.

Gunshot wounds – Important details

 A very important aspect of treatment, often neglected in a shooting scenario is a good history. Not why the person was shot, but details of the situation. If possible, obtain an unfired cartridge, preferably directly from the weapon. The caliber will be printed on the bottom of the casing. The bullet itself can be described over the radio or telephone during your initial contact and the shell relinquished to the emergency department staff upon your arrival there. Determine the approximate range.

Powder residue, having the appearance of pepper sprinkled around the wound, is an indication that the patient was shot from close range. Determine if the weapon used was a rifle, shotgun or handgun and the type.

If the information is available, let the receiving facility know if the assailant is right or left handed, even if the shooting is the result of a suicide attempt. This will help to determine the probable angle of entry and therefore the probable path the bullet took. The physical location of the assailant, relative to the victim, is also helpful to know.

Gunshot wounds in a survival situation

In a situation where access to a hospital is impossible, certain other procedures must be followed. Entire books have been written on trauma surgery. It goes without saying, the subject cannot be adequately covered in this article alone.

In this type of situation, there will hopefully be an experienced medic with a surgical set available. If the patient is going to die without surgical intervention, he has little to lose by having a medic or paramedic or nurse or EMT working on him.

Using whatever anesthesia or analgesic agent is available, the patient is made as comfortable as possible. The wound is then surgically opened. The incision must be long enough to reveal the damaged area (the permanent cavity) below.

Major vessels that are still bleeding must be ligated (tied off) or cauterized. The bloody, pulpy mush that can freely be removed from the wound is discarded. Bone and bullet fragments must also be removed. In the past, devitalized tissue was immediately removed. It is now believed that any tissue still attached to living tissue has a chance for survival. To this end, debridement is delayed.

The wound is packed with antibiotic-impregnated dressings and covered with a sterile dressing. The patient is given IV antibiotic and kept as comfortable as possible.

At 12, 24, 36, 48, 72 and 96 hours post op the packing is removed. The wound is irrigated with sterile saline and fresh antibiotic packing replaced. This procedure allows the wound to heal from the inside out.

After about five to seven days, the packing is removed and the demarcation between viable and dead tissue should be obvious. The dead tissue is then surgically removed and a secondary closure performed.

What you should take away from this article

This article was not an attempt at teaching field surgery, but an attempt to inform the reader of the emergency care that should be rendered to the victim having one or multiple gunshot wounds. Additionally, it was intended to make survivalists and preppers aware of some of the basics in gunshot treatment.

The individual who has sustained a gunshot wound should attempt to remain calm and should apply direct pressure to the wound while calling for help. Lying still with legs elevated will help increase the chances for survival. Exotic maneuvers such as pouring gunpowder into a wound, then igniting it only work in the movies.

The person who desires to assist the victim of a gunshot wound need only remember and put to use the basics:

  • Airway management — make sure the victim’s airway is not obstructed by blood, vomit, or another foreign body.
  • Breathing — make sure the victim is breathing at least 12 times a minute. If he isn’t, assist him to do so.
  • Circulation — do all you can to keep the victim’s heart beating, CPR (Cardio Pulmonary Resuscitation), if necessary, should be performed.
  • Shock —maintaining the victim’s blood pressure, keeping him out of shock, should eliminate the need for CPR. Control bleeding, preferably with direct pressure, elevate the legs, keep him warm, administer IV fluids (if qualified to do so), give oxygen if available, and get definitive medical care.

These are the keys to the proper field management of the gunshot victim.

Other Useful Resources:

Find Out What’s the Closest Nuclear Bunker to Your Home

Learn how to Safeguard your Home against Looters

A Green Beret’s guide to combat and shooting during a major disaster

Survival Lessons from the 1880s Everyone Should Know

3 thoughts on “Field Management of Gunshot Wounds”

  1. Very good article!! As a First Responder in a remote area for hit every detail….GOOD JOB! Going to print it as a reminder! Thanks

  2. Understand that I have no opinion about any issue in this article. My limited experience and education in the field causes me to withhold judgment here.

    However, the opinions expressed in the article would have more impact with me if the author had an “M.D.” behind his name, or would represent that everything he said in the article was reviewed and approved by, say, an ER physician or surgeon.

  3. I will add to my previous comment that the article appears to be well-written and accurate (but, again, I’m judging it with my limited skill and ability in the field).

    I just read another article on a different subject on another site. The author’s opinions received blistering comments by a seemingly well-qualified person in the field. And so it goes with the internet.

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