When a patient is shot: What you need to know
Assessment of gunshot patients, knowing when to transport, and preserving evidence are key in treating gunshot wounds
Patients who have sustained gunshot wounds (GSWs) to the head, neck or chest are among the most challenging for ED nurses, says Carerie Kozak, RN, MSN, CEN, MICN, clinical nurse specialist/educator for emergency services at Loma Linda University Medical Center and Children's Hospital (CA). "These patients are typically very critical and require life saving measures immediately," she stresses. "It is imperative that you have the appropriate resources, knowledge, and skills."
The damage done by gunshot wounds can range widely. "Wound tracks can vary between clean, uninterrupted bullet paths causing minimal damage, to those where the bullet acquires a tumbling action on impact and has multiple directional changes after contacting dense organs or bone structures," says Jeff Bender, RN, BSN, MIC, associate trauma nurse coordinator at Loma Linda.
The injuries can be further complicated by bullet fragmentation creating multiple wound paths, adds Bender. "Additional injuries are not always isolated to the bullet track," he notes. "The same tumbling bullet can cause a cavitation effect that results in a radiating injury to the tissue surrounding the wound track."
Preserve evidence. Photographs of the wound, taken in conjunction with law enforcement or the medical examiner, may be useful as documentation for criminal prosecution, says Kozak. "Photography can help differentiate between entrance or exit wounds, profile, range, energy, or caliber," she explains. "This information may help in patient treatment, scene information, mechanism of injury, and criminal cases."
When taking a picture of a gunshot wound, place a measuring bar with the wound to assist in documenting length and width, Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, advises. "A picture should be taken with this ruler and a second one without it," she says.
Color bars are also helpful. "These determine the degree of color in and around the wound," Bradley explains. "Black marks can be detected from burns, red colors are highlighted for the blood. This presents a graphic presentation of color, since the photo compares the wound and the color bar."
If photos are taken, this should be documented in the medical record. "If they are needed for criminal investigation, the police will supoena them from the medical records department," says Bradley. "They should not be handed over to the police without going through the appropriate procedures."
Photos should be included in the medical record as a documentation tool, says Bradley clinical director of emergency/express care services at Loma Linda. "The photo should have the medical record number of the patient, the date and time of the photo, and the name of the photographer," she explains.
Be careful to preserve anything that could assist the police in the crime investigation, says Bradley. "This includes such things as not cutting through the bullet hole on the clothing, and preserving bloody clothing in a paper bag rather than a plastic belonging bag."
Preserving evidence is critical, stresses James Armstrong, RN, BSN, CCRN, CFRN. "With the amount of public viewing of the O.J. Simpson trial, no one can doubt the importance of evidence and the proper collection of that evidence," he says.
Read your hospital's policy on evidence preservation. "If you have no policy or it seems outdated, here is a perfect time for a little inservice education and PR," recommends Armstrong.
Invite your local police department and medical examiner/coroner to your ED for an organized inservice, Armstrong advises. "Find out what evidence they require and how best to collect and preserve this evidence for them," he suggests.
Your policy should address what to do if you find a gun on a patient in the process of assessment, says Armstrong. "A loaded weapon in the hands of an inexperienced person is absolutely dangerous," he stresses. "Work together with your hospital security force or law enforcement agency to handle an event like this."
Does the patient need to be transported? According to the American College of Surgeons Guidelines on Trauma Care, any penetrating injury of the head, neck, chest, abdomen, or groin should be seen in a trauma center, notes Armstrong. "If your ED is some distance from a trauma center, the challenge is to keep the patient alive long enough to either get them into surgery or rapidly transport them to a qualified facility," he says.
Know your limitations, stresses Armstrong. "Not all gunshot wounds are of a critical nature and some can be taken care of very nicely in the ED. But recognizing what your facility can and can't do for this patient is absolutely important," he says. "If you can't do what's best for the patient, get them to a facility that can, and by the fastest method available. Have a documented, easy to understand transport policy that can quickly be implemented."
A transport policy should outline what the receiving hospital requires of the sending, such as treatments, procedures, documentation, x-rays, and mode of transport, says Armstrong. "If the receiving hospital does not specify a mode of transport, the policy should address that. Consider the capabilities of ambulance, ALS or BLS, helicopter, and fixed wing aircraft and what is in the best interest of the patient."
Keep the patient and family informed of the need to transfer, where the patient is being transferred, and how the process is progressing, says Armstrong. "Also check with the transfer agency to find out if a family member can accompany the patient," he recommends. "But do not send family members ahead of the patient. If something goes wrong or the patient deteriorates at your facility, you don't want the entire family or important members in transit."
A nurse-to-nurse exchange of information between the two facilities is imperative, says Armstrong. "This is not only a courtesy but gives the receiving nurse information to better prepare for the patient's arrival," he explains.
Here are some tips for managing patients with gunshot wounds:
Don't go by wound appearance alone. "Avoid any presumption of wound severity based solely on wound appearance," says Bender. "Wound severity is highly unpredictable and is based predominantly on the following factors: physical characteristics of the bullet, energy of the bullet, action of the bullet after entry, and contact with dense tissue or bone structures."
There is a tendency to focus initially on the wound, but it is imperative that the nurse manage the ABCs first, says Bradley. "Then do the secondary assessment, which includes a more detailed exam of the wound," she explains. "Another thing to keep in mind is that when the patient arrives in the ED we don't often know what they have been shot with or how many times."
Although the wound may appear small on the surface, internally it can be devastating with cavitations, fractures, and hemorrhaging, says Bradley. "The extent of injury should not be underestimated, a full resuscitation should occur regardless of how benign the external wound may appear."
Prioritize treatment. The treatment of a victim of a gunshot wound should be prioritized by airway, breathing, and circulation, stresses Armstrong. "Make sure the patient has a viable airway, and maintain it," he says. "If needed, secure an airway via intubation or surgical procedure. Make sure the patient is breathing efficiently and support that breathing with 100% oxygen."
Assess circulation adequately. "Adequate circulation should be supported by a minimum of two large bore IV lines that are plumed with blood tubing and warm fluids, and with frequent assessment of circulation through vital sign monitoring," says Bender. "Also, consideration should be given to assessment of adequate circulation distal to the wound, particularly when dealing with a gunshot to an extremity."
Consider the possibility of spinal trauma. "The bullet may have hit the spine or the patient may have fallen against something," warns Armstrong. "Some of the roughest handled patients I have seen in my 21 years of practice have been penetrating traumas, as no one thinks about spinal damage."
Expose the patient. "Do a good secondary assessment, including the back, to find all other sites of penetration," advises Armstrong. "Remember: Not all gunshot wounds bleed, and not all are obvious. Look in the hair, under the arms and between the legs and folds of skin. Bullets have been known to enter the body through already existing openings such as the anus, nostril, mouth, and ear canal."
Be prepared to manage shock. "Type and cross matching of blood should be included with the initial lab work in order to be prepared to promptly manage hemorrhagic shock," says Bender.
Obtain lab results early. "Chest, abdomen, spinal, and appropriate extremity x-rays should be obtained early due to their benefit of showing bullet and fragment location, pneumo-/hemo-thorax, bone fractures, and direction of the bullet track," Bender advises.
Reduce risk of infection. "The wound itself should be dressed as soon as possible and handled as little as possible to decrease risk of infection," says Bender.
The nurse should keep in mind that bullets create dirty wounds and the potential for infection is great, stresses Bradley. "The nurse should verify patient allergies and check with the physician on which antibiotics should be administered," she adds. "Cross contamination of wounds should be prevented. Each wound should be cleaned and dressed using sterile/aseptic procedures."
Start antibiotic treatment in the ED. "Antibiotic treatment should be initiated in the ED if possible, as prophylactic treatment," notes Bender.
Prepare patient for OR. "All documentation and pre-op process should be complete in order to quickly facilitate any need to manage the patient in the OR," says Bender.
Determine whether the gunshot was low or high velocity. "In high-velocity injuries, considerable tissue damage is to be expected from the energy delivered," notes Kozak. "The severity of the wound in the body is related to the amount of kinetic energy deposited in the body."
The efficiency with which kinetic energy is deposited is influenced by: 1) the velocity of the projectile along its trajectory; 2) the deformation of the missile within the tissue; and 3) the elasticity and density of the tissue in the missile pathway, says Kozak. "This may suggest the need for exploration of the wound, provided it does not involve the peritoneum," she explains.
Know the potential wounding power of medium- (handguns) and high- (rifles) velocity gunshot wounds. "They both make holes, but their individual wounding capacities are very different," Armstrong explains.
Don't try to determine entrance and exit wounds. "This can be very difficult to one not trained and experienced in the variations," says Armstrong. "This is also an important legal point if you are documenting this, as it will be disputed in an investigation. It is better to document where the penetrating sites are and what they look like."
Nurses should not focus on which is an entrance wound or which is the exit wound, says Bradley. "Instead, they should provide an accurate description of the wounds that will help make that determination," she explains. "In the documentation, the wound appearance should be noted, burning of the tissue, or tattooing, which may indicate the range at which the gun was shot."
Don't try to guess the size of the projectile on x-ray. "This is extremely difficult as it is hard to determine the depth of the projectile on film," Armstrong explains. "I have seen crime lab photographs of x-ray film showing several projectiles of seemingly the same size. Upon examination, they were all different sizes, just at various depths in the body."
Assume injuries are severe. "Any penetrating wound of the head, neck, chest, abdomen, or groin should be treated as severe until proven otherwise, even if the patient has stable vital signs and is speaking appropriately to you," Armstrong says.
Assess on an ongoing basis. "Until the surgeon gets in there, no one has any idea of what the bullet(s) have hit or damaged. You should be prepared for anything," says Armstrong.
Be prepared for quickly changing scenarios. "Make sure your operating team has been alerted, and you are prepared to transfuse if need be," says Armstrong. "I have seen many patients deteriorate rapidly. I have also seen many patients mistreated because the severity of the injury had been underestimated."
Ask about patient's position. "Obviously this information may be unknown based on circumstance, but specific inquiry should be made as to the position of the patient relative to the assailant and the location of the wounds," says Kozak.
Look for smudging. "The presence or absence of smudging or powder burns should be noted," says Kozak. "Powder burns or smudging suggests the proximity of the firearm upon discharge. To have powder burns, the firearm typically has to be very close or have skin contact."
Consider safety. "As most GSWs involve violence and/or criminal activity, make sure that there are no other weapons on the patient, and the patient is not a threat to you or themselves," says Armstrong. "Security should be extra vigilant during the initial resuscitation, for weapons that need to be secured, patient restraint, and restriction of access to the treatment area of anyone not needed or authorized in the treatment area."
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