How do gunshot wounds work

Does the ball have to go?


When it comes to gunshot wounds, even experienced surgeons are exposed to numerous Hollywood myths.

Does the patient need an antibiotic after a gunshot wound? Does the ball need to be removed? How extensive does the debridement have to be? What role does the distance from which the shot was fired play a role? The participants in a California study failed particularly in answering these questions.

The 115 clinicians all came from large Level I or II trauma centers. The majority (57%) had even attended ATLS® (Advanced Trauma Life Support) courses on a regular basis. But it is precisely this ATLS® concept that seems to promote the spread of misinformation in connection with gunshot wounds: For example, the ATLS® manual states that gunshot wounds are fatal at close range, but their destructive potential disappears rapidly with increasing distance. According to the study authors, this suggests that shots from a distance are less dangerous. Corresponding wounds would possibly be underestimated. According to the researchers, gun shots, for example, could be fatal even at a distance of over 130 meters.

Tissue damage is overestimated

The manual developed by the American College of Surgeons in the 1980s also states that the temporary cavity hit by the bullet could be 30 to 100 times the diameter of the projectile. If that were the case, the Fresno researchers argue, a complete amputation would be required if the extremities were shot through. Under these circumstances, when shooting through the abdomen, the majority of the intestines would have to be resected. "Even extremely fast rifle bullets with speeds of 1 m / s hit a maximum cavity 12.5 times the bullet diameter," say Hafertepen et al.

According to the authors, the necessity and extent of debridement are greatly exaggerated. Of course, the removal of dead tissue is important to avoid wound infection. However, if you follow the recommendations, you would have to include the entire firing channel. However, this makes little sense, the researchers write, considering that the tissue was only briefly stretched over most of the way. Many parts of the body seem to tolerate this relatively well; the energy is distributed without much damage. In this respect, the concept “the more energy, the greater the damage” does not apply in principle.

Measures like in the Wild West

And the Californian experts dispel another myth: “The bullet has to come out in any case” - this dogma is known from numerous westerns. Hafertepen et al. in many cases unnecessary. Lead poisoning is at best realistic if the projectile comes into contact with synovial fluid or lands in an intervertebral disc. Extraction is also indicated if the ball is stuck in a vessel or in the myocardium.

Antibiotics essential

Another danger is underestimated: the introduction of pathogens through the sphere itself or through rags of clothing that are carried away on its way. Many sources state that antibiotic therapy after gunshot wounds can be dispensed with or do not go into it at all. According to Hafertepen and colleagues, the assumption that the bullet is sterile due to the heat generated when it is fired has been refuted by several studies. Treating a patient with a gunshot wound with antibiotics is essential, according to the experts.

Seminars help

The participants in the Californian study were at least capable of learning: after the first survey, the research team had them take part in a 40-minute specialist seminar in which all the problems mentioned were discussed and the current state of research was presented. The proportion of correctly answered questions increased from 34 to 78 percent. After all, 68 percent wanted to change their wound management in connection with gunshot wounds after the seminar.

Original publication: Hafertepen SC et al .: World J Surg 2015; online February 10th