DRG Category: 205
Mean LOS: 5.5 days
Description: Medical: Other Respiratory System Diagnoses With Major Complication or Comorbidity
DRG Category: 228
Mean LOS: 9.2 days
Description: Surgical: Other Cardiothoracic Procedures With Major Complication or Comorbidity
DRG Category: 405
Mean LOS: 12.6 days
Description: Surgical: Pancreas, Liver, and Shunt Procedures With Major Complication or Comorbidity
DRG Category: 799
Mean LOS: 10.7 days
Description: Surgical: Splenectomy With Major Complication or Comorbidity
DRG Category: 958
Mean LOS: 8.3 days
Description: Surgical: Other Operating Room Procedures for Multiple Significant Trauma With Complication or Comorbidity
Penetrating trauma from a gunshot wound (GSW) or firearm injury can cause devastating injuries. The most commonly injured organs and tissues are the intestines, liver, vascular structures, spleen, and intrathoracic structures. Evaluating injuries is difficult; it is important to determine the type of weapon, energy dissipated from the weapon, firing range of the weapon at the time of injury, and characteristics of the injured tissue.
In the United States, 35,000 to 40,000 people are killed each year in gun-related events. The United States has 4% of the world's population but possesses 50% of the world's privately owned firearms. Firearm deaths are the highest in Alaska, Mississippi, New Mexico, Wyoming, and Alabama and lowest in Massachusetts, New York, New Jersey, and Hawaii. Approximately 63% of gun deaths are suicides, 36% are homicides, and the rest are from other causes, primarily unintentional death. GSWs can be perforating, when the bullet exits the body, or penetrating, when the bullet is retained in the body. GSWs can lead to the need for extensive débridement, resection, or amputation. Among the many complications are sepsis, organ dysfunction, exsanguination, and death.
The energy of the missile is dissipated into tissues of the body, causing destruction of vital and nonvital structures. When the missile enters the body, it creates a temporary cavity, which stretches, distorts, and compresses the surrounding anatomic structures. The cavity that is produced often has a greater diameter than the missile itself. In a situation called blast effect or muzzle blast, damage occurs in structures outside the direct path of the missile. High-velocity missiles (bullets from shotguns, rifles, or high-caliber handguns) cause extensive cavitation and significant tissue destruction, while low-velocity missiles (bullets from low-caliber handguns) have limited cavitation potential with less tissue destruction. Another characteristic of missiles is the yaw, which is the amount of tumbling and movement of the nose of the missile that occurs. The more yaw, the greater the tissue damage.
No clear genetic contributions to susceptibility have been defined.
Penetrating injuries from gunshot wounds and stab wounds, which are on the increase in U.S. preteens, teens, and young adults, are more common in males than females. In urban areas, drive-by shootings are increasing, and in some cities they are associated with half of all youth gunshot wounds. Males have different patterns of injury than females, and a higher injury severity. Analysis of trauma outcomes indicates that, following traumatic injury, males have higher rates of multiple organ failure, pneumonia, and sepsis than females, creating health disparities for men (Marcolini et al., 2019). Trauma is the third leading cause of death in people ages 45 to 65 years and the seventh leading cause of death in people older than 65 years.
In the United States, Black youth ages 15 to 24 years have the highest homicide rate from GSWs, followed by Hispanic youth. Suicide rates are highest among Native American males and non-Hispanic white males. Penetrating injuries from gunshot wounds and stab wounds are more common in non-Hispanic Black persons than in non-Hispanic White persons. Non-Hispanic Black males have adjusted firearm death rates from two to seven times higher than males of other groups. Healthy People 2020 reports that non-Hispanic Black persons have the highest injury death rate in the United States (79.9 injury deaths per 100,000 people), followed by non-Hispanic White people (79.2), Native American people (78.2), Hispanic people (45.5), and Asian/Pacific Islander people (25.6). Geographic information system mapping has shown that impoverished neighborhoods have a higher incidence of gunshot injury than other neighborhoods (Bayouth et al., 2019). Socioeconomic status and injury are linked, with people living with lower incomes having higher risk. Children under 14 years of age living in rural areas have higher rates of unintentional firearm injuries than urban children have. Recent work has shown evidence that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the distance from major trauma centers. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury (Healthy People 2020).
Countries with high levels of civil strife or political instability or are at war have a high prevalence of GSW death and disability. South Africa, Brazil, Colombia, El Salvador, Guatemala, Honduras, and Jamaica have high rates of gun-related deaths as compared to other countries. Mortality rates are lowest in Japan and highest in the United States.
PLANNING AND IMPLEMENTATION
Collaborative
Maintaining a patent airway, maintaining oxygenation and ventilation, and supporting the circulation are the first priorities. Assist with endotracheal intubation and mechanical ventilation. Maintain the Pao2 at greater than 100 mm Hg and the Paco2 at 35 to 45 mm Hg. The patient may require placement of a tube thoracostomy to drain blood and relieve a pneumothorax.
The focus is on four broad components of care: control of bleeding, identification of injuries, control of contamination, and reconstruction of the injured area. Restoring fluid volume status is critical in maximizing tissue perfusion and oxygenation; the use of pressure infusers and rapid volume/warmer infusers for trauma patients requiring massive fluid replacement is essential. Administering warm blood products and crystalloids assists in maintaining normothermia. Be prepared to administer vasopressors after fluid volume status is stabilized. Patients who require massive fluid resuscitation are at risk for developing hypothermia, which exacerbates existing coagulopathy and compounds their hemodynamic instability. Paramount in managing patients is a rapid fluid resuscitation with blood, blood products, colloids, and crystalloids through a large-bore peripheral IV catheter or a large-bore trauma catheter.
Patients frequently require surgical exploration to identify specific injuries and control hemorrhage. After surgical exposure is obtained, any of the following may be required: assessment of structures, control of hemorrhage, débridement, resection, or amputation. If definitive surgical intervention is not possible because of the patient's instability, a temporizing method known as damage control may be instituted. Damage control consists of the placement of packing to achieve a temporary tamponade, correction of coagulopathy, and aggressive management of hypothermia. The patient is then transferred to the critical care unit for continued monitoring and stabilization. The “second look” surgical exploration is generally done in 24 hours for definitive surgical intervention.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Antibiotics: Prophylactic antibiotic use is controversial; surgeons follow culture results and institute antibiotics sensitive to the organism that was cultured | Varies with drug | Second-generation cephalosporins or cephamycin | Prevent gram-negative infections when there is traumatic violation of the gastrointestinal tract |
| Low-molecular-weight heparin (enoxaparin, dalteparin) | Varies with drug | Anticoagulant | Prevents thromboembolism during periods of immobility after hemorrhage is controlled; not generally administered in patients with neural injuries |
Other: Many trauma surgeons may choose to administer a tetanus booster to patients with chest trauma whose immunization history indicates a need or whose history is unavailable.
Independent
In the emergency phase of treatment, maintain the patient in a supine position unless it is contraindicated because of other injuries. Ensure adequate airway and breathing in this position. Avoid the Trendelenburg position because it may have negative hemodynamic consequences, increase the risk of aspiration, and interfere with pulmonary excursion. If the patient can tolerate the position, elevate the head of the bed to limit the risk of aspiration and to improve gas exchange.
Wound care varies, depending on the severity of wounds, whether an open fracture is present, and what type of fixation device is applied. Wounds and any exposed soft tissue and bone are covered with wet, sterile saline dressings. Standard Betadine-soaked dressings may not be used because of the need to limit iodine absorption and skin irritation. To decrease the risk of infection of the patient, use a gown, mask, gloves, and hair covers when caring for patients with extensive wounds. Document the size, description, and healing of the wound each day, and notify the surgeon if there are signs of wound infection. Use universal precautions in handling all bloody drainage.
If another person has initiated the violence toward the patient, consider assigning the patient a pseudonym for all hospital records to prevent another assault. Do not provide any information about the patient over the phone unless you are sure of the caller's name and relationship to the patient. If you fear for the patient's safety, talk to hospital security about strategies to ensure the patient's safety. If the patient has a self-inflicted injury, make a referral to a clinical nurse specialist or discuss a psychiatric consultation with the surgeon. If the patient is self-destructive, initiate suicide precautions according to unit protocol.
If the patient is being held by police, remember that the patient receives competent and compassionate care even when under arrest. Determine from hospital policy the regulations about visitors if the patient is held by the police. Provide a supportive atmosphere to promote healing of the injury, but use care to avoid being drawn into the legal aspects of the patient's arrest.
Evidence-Based Practice and Health Policy
Parker, S. (2020). Estimating nonfatal gunshot injury locations with natural language processing and machine learning models. JAMA Network Open. Advance online publication. https://doi.org/10.1001/jamanetworkopen.2020.20664
- The author aims to determine if natural language processing and machine learning methods can predict the locations of nonfatal shootings and improve the accuracy of national estimates of gunshot injuries. The authors used 59,025 gunshot wound cases from the National Electronic Injury Surveillance System Firearm Injury Surveillance Study.
- The primary outcomes were injury location and subsequent estimation of nonfatal gunshot injury location. Patients with these injuries were predominantly male, Black, and ages 15 to 24 years. The analysis was able to determine the most likely locations (street, highway) for gunshot injuries. The findings showed that machine learning models may be used to determine location, and that highways or streets were the most likely location rather than in the home.