Types of Patients V: GSWs

The Preface

Guns are for pansies.

No matter what a person believes about the 2nd amendment, no matter how cool a person thinks guns feel or look or sound, hurting or killing people (or animals, for that matter) by shooting them is only for wimps who can't or won't get in close and do it with their bare hands. Easy to kill or mame from 20, 30 yards when one has the right technology...and is weak. And lazy.

But people do because people are. And sometimes in the ER we end up with the aftermath.

Gun shot wounds run the gamut from serious to superficial, intentional to accidental, traumatic to tragi-comic. Not surprising, nursing care for a patient with a gun shot wound must include attention to and management of the patient's emotional state, as well as the emotional states of the patient's family and/or friends.

In terms of trauma, damage to the body from bullets is the result of velocity and impact. Traveling at a high rate of speed, bullets pierce and tear flesh, impact and shatter bone, and penetrate, macerate, or do blunt percussive trauma to dense organs. As well, the trajectory of a bullet once it has entered the body can warp and create greater internal damage than is apparent from external wounds.

If it bleeds it leads applies. First nursing priority after establishing a patent airway and breathing: stop or retard active bleeding. Direct pressure on external wounds is optimal, despite the fact that it might not be enough.

Second nursing priority: replace blood loss with the establishment of two large bore IVs and boluses of normal saline. Preferably, specialized blood tubing should be used on at least one IV line for the purpose of administering blood later when it is cross-matched and available. When in doubt, unmatched O blood can be given.

Third nursing priority depends upon the location of the wound and the possible damage to internal structures.

With wounds to the head or excessive blood loss, neurological assessment and continuous reassessment are necessary. With all disruptions in skin integrity the risk of infection is great, but with gun shot wounds to the head, potential for infection of the brain or cerebral spinal fluid is life-threatening. Once active bleeding is stopped, sterile dressings over wounds is a must.

Gun shot wounds to the chest require respiratory assessment, possibly a chest tube to drain blood from the lungs or pleural space, and bedside ultrasound to ascertain damage to the heart, pericardium, or great vessels. Portable x-ray (these patients should not leave the ER or be left unattended by a nurse) to confirm number of bullets and location is advisable.

Unless the diaphragm is injured and possible paralyzed, abdominal wounds are less life-threatening, but quick radiography and CT are necessary prior to emergency surgery. The risk here is infection, given the fact that the contents of bowel and bladder are contaminants and waste products of the body. Leaking these into the abdominal cavity through bullet holes allows the onset of peritonitis. Injuries to the liver, pancreas and spleen are also common.

Wounds to the extremities are usually through-and-through wounds. Determining entry and exit and the bullet's trajectory is important to estimate and later establish all relevant injury. Orthopedic consultation/surgery might be necessary, especially for wounds to the hand(s).

Once life-threatening situations are controlled and risks decrease, emotional care of the patient begins. Addressing the patient's fear and/or grief of loss of function or appearance is paramount, as well as their emotional response to the situation surrounding the shooting. Even with accidental gun shot wounds, the emotions of anger and blame can compromise the physical well-being of the patient. Addressing emotional concerns of the patient and the patient's family and/or friends is part of ER nursing.

The Epilogue

The NRA and other gun nuts will tell you that guns don't kill people, people kill people. However philosophically true that may be, the fact is that it is the bullet that does the damage.

I know. I've seen it.