Triage Review of Gunshot and Stab Wounds

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Introduction   

In 2022, firearm injuries in the United States were the leading cause of death among children and teenagers aged 1 to 19 years and was one of the five leading causes of death for individuals aged 1 to 44 years (5, 10). Most people who sustain a firearm injury do not die; however, in the United States, about 132 people die from a firearm injury every day (5).

The rates of firearm violence vary by population. Firearm homicide rates are higher in the Hispanic/Latino, Black/African American, and Native American/Alaska Native populations (5, 10). Men account for 87% of firearm injuries and 86% of firearm deaths (5, 10). Firearm suicide rates are highest among adults aged 75 years and older and in individuals of Native American/Alaska Native and non-Hispanic Caucasian cultures (5).

Stab wounds contribute to more than 400,000 injuries and 1,500 deaths in the United States each year (1, 9). Additionally, stabbing is the most common type of violence worldwide (8). Most stabbings that occur are intentional acts of violence; however, stab wounds can also be accidental when an individual falls on a pointed object, particularly those who work in high-risk industries, such as construction and manufacturing (8). Teenagers and young adults account for the majority of knife victims in urban populations (11).

Gunshot and stab wounds cost the United States tens of billions of dollars every year in medical and law enforcement costs and lost productivity costs (5, 12). Acute care hospitalizations, temporary and permanent disability, and long-term physical and mental health care and rehabilitation contribute to these costs (12).

Additionally, exposure to any form of trauma, especially in childhood, can increase the risk of mental illness and suicide; smoking, alcohol, and substance abuse; chronic diseases like cancer, heart disease, and diabetes; and social issues such as poverty, crime, and violence (12). Nurses play a pivotal role in teaching patients and community members how to prevent injuries and violence, including the importance of breaking intergenerational cycles of violence.

Pathophysiology

Penetrating trauma is an injury caused by a foreign object piercing the skin that results in damage to the underlying tissues and an open wound (2). In penetrating trauma, the object remains in the tissue or passes through the tissue and exits the body. Penetrating trauma can result from fragments of a broken bone, gunshots, and knife wounds and can result in shock and infection (10).

There are two types of penetrating trauma: perforating injury and puncture injury. A perforating injury occurs when an object enters the body and passes through it, as in the case of both an entry and exit wound when a bullet enters and exits the body. A puncture injury does not have an exit wound and is due to something sharp or pointed, such as a stabbing injury with a knife (10).

A gunshot wound is caused by a bullet that is discharged from a gun. In a stab wound, a pointed object (knife, broken bottle) is thrust into the body. In both cases, a projectile that passes through tissue decelerates and transfers kinetic energy to the tissue. The penetrating object forms a cavity from the space left by the tissue that is destroyed; this is called permanent cavitation.

Projectiles of medium and high velocity cause not only damage to the tissues they contact but also result in a secondary cavitation injury as the object enters the body and creates a pressure wave forcing the tissue out of the way, which creates the second cavity. The tissues then move back into place, which eliminates the cavity, but considerable damage is already done by the cavitation.

In stabbings, the depth of the injury is typically greater than the width. In gunshot injuries, dense organs like the liver and bone absorb more kinetic energy than less dense organs, which causes greater injury (2, 10).

The most common areas of injury in both gunshot and stab wounds are the head, neck, chest, abdomen, pelvis, and extremities (2).

The specific injuries include (2, 10):

• Head: Penetrating head and traumatic brain injuries
• Neck: Tracheobronchial, esophageal, vascular, cranial nerve, pneumothorax injuries
• Chest: Cardiac tamponade, hemothorax, pneumothorax, tracheobronchial injury, diaphragmatic injury, spinal cord injury, fractures, vascular injury
• Abdomen and pelvis: Diaphragmatic injury, hollow viscus perforation, solid organ injury, genitourinary trauma
• Extremities: Neurovascular injury, fracture, compartment syndrome

Gunshot or stab wounds are the main causes of penetrating abdominal trauma with the small and large bowel, liver, and intra-abdominal vasculature being affected the most (10). Regarding stab wounds, the most common site of injury is the intestines followed by the great vessels, diaphragm, mesentery, spleen, liver, kidney, pancreas, gallbladder, and adrenal glands (7).

These injuries to the abdomen are life-threatening because abdominal organs bleed profusely. Injuries to the pancreas cause autodigestion issues, injuries to the liver cause shock because of the liver’s large blood supply, and injuries to the intestines can cause leakage of fecal matter, which can cause sepsis (10). Although abdominal stab wounds are more common than abdominal gunshot wounds, abdominal gunshot wounds are associated with eight times the mortality rates than abdominal stab wounds due to their higher kinetic energy (7).

Clinical Signs and Symptoms

The most prevalent clinical signs and symptoms of gunshot and stab wounds are those associated with hemorrhagic and obstructive shock (2).

Additional signs and symptoms include (2, 3, 7, 10):

• Hypoxia
• Oliguria
• Fractures
• Peritonitis
• Beck triad
• Tachypnea
• Tachycardia
• Bradycardia
• Hypotension
• Tissue edema
• Soft tissue injury
• Tracheal deviation
• Distended neck veins
• Neurological changes
• Narrow pulse pressure

The presence of an impaled foreign body (e.g., knife) and/or the presence of excessive blood on or near the patient is indicative of penetrating trauma. The nurse should also note that a fever, abdominal distention, abdominal pain, rebound tenderness, rigidity, and guarding could be indicative of peritonitis in abdominal trauma, especially since intraperitoneal injury occurs in 98% of abdominal gunshot wounds and 30% of abdominal stab wounds (2).

Assessment

The primary assessment in patients with a gunshot or stab wound includes the Airway, Breathing, and Circulation (ABC) assessment that focuses on the patency of the airway, the presence of the patient’s breathing, and the patient’s circulatory status (7, 10). Assessing the patient’s neurologic and vascular status is imperative since penetrating trauma can damage blood vessels and nerves (3, 7, 10). Significant blood loss is associated with penetrating trauma, which can lead to hemorrhagic shock.

In abdominal trauma, the nurse should examine the patient’s flank, back, and groin for wounds that could terminate in the abdominal cavity. The nurse should note if the abdominal fascia is compromised and should assess for injuries that have penetrated the thoracoabdominal and flank areas (2).

Patients who are older than 65 years, who are prescribed anticoagulants or antiplatelet medication therapy (warfarin, heparin), and who have medical conditions, such as advanced liver disease, advanced liver disease with coagulopathy, and diabetes such be carefully monitored (7). Patients who are intoxicated (alcohol, prescription drugs, and/or illegal substances) should also receive regular assessments to maintain patient safety (7).

When the patient presents with a gunshot or stab wound, the nurse should completely undress the patient since clothing can obscure additional injuries. The scalp, axilla, perineum, and groin should be thoroughly assessed because these are areas that can easily camouflage injury. The nurse should remember that the most evident wound or wounds may not be the most concerning since internal injury is a major concern associated with penetrating trauma (7).

It is important that the nurse collect information about the weapon used that created the penetrating injury. If any of the weapon fragments can be retained, such as dislodged bullets in the instance of a gunshot wound, the nurse should collect these (3).

Assessment questions the nurse should ask the patient, witnesses, emergency medical technicians (EMTs), and law enforcement personnel include (7):

• When did the injury occur?
• What instrument or weapon was used?
• What was the make, model, and caliber of the firearm?
• How long and wide was the sharp object used for penetration?
• How was the patient positioned during the shooting or stabbing?
• What path did the implement travel (upward, downward)?
• Was there substantial blood loss at the scene?

The nurse should never attempt to dislodge impaled foreign bodies (e.g., knives) since they may be sealing injured blood vessels, thus preventing hemorrhage (2). The impaled object should only be removed by the surgical team during the surgical procedure.

Diagnostics

The nurse should anticipate that several diagnostic tests will be ordered for the patient presenting with a gunshot or stab wound. The specific diagnostics depend not only on the injury site, but also on the patient’s signs and symptoms, medical history, and social history.

Potential diagnostics include (2, 3, 7):

• X-ray
• Ultrasound
• Laparoscopy
• Bronchoscopy
• Esophagoscopy
• Toxicology screen
• Echocardiography
• Coagulation studies
• Arterial blood gas (ABG)
• Complete blood count (CBC)
• Diagnostic peritoneal lavage (DPL)
• Magnetic resonance imagery (MRI)
• Computed tomography (CT) with intravenous contrast
• Focused assessment with sonography for trauma (FAST)

Plain film radiography should be taken with multiple views, including the non-affected tissue both above and below the injury site. This is to show the weapon’s (e.g. bullet, knife blade) components, to identify any fractures, and to identify information about the weapon’s internal track. Imaging can also detect distant injuries due to stray fragments resulting from impact. If the weapon component contains metal, as is the case with a bullet or knife blade, MRI is contraindicated since metal can damage the machine (3).

CT angiography can detect vascular and soft tissue injuries, as well as flank and back wounds to assess for solid organ injury. A CT scan can also detect cranial and skeletal injuries. If bullet migration is suspected, ultrasound or intraoperative fluoroscopy is performed to detect the projectile’s exact location before surgery (2, 3).

Diagnostic peritoneal lavage (DPL) is indicated in abdominal penetrating injuries and entails irrigating the peritoneal cavity with fluid. This is performed to remove blood, fecal matter, and purulent secretions from the peritoneal cavity to decrease the risk of infection and enable an improved view of the abdominal cavity. The nurse should note that retroperitoneal injuries can easily be missed on DPL and FAST diagnostics (2).

Diagnostic laparoscopy is a surgical diagnostic procedure that is used to visualize the abdominal cavity with a laparoscope inserted through an incision in the abdominal wall. Peritoneal fluid can be collected, acute abdominal pain evaluated, and foreign bodies located and identified with this diagnostic (2).

An abdominal or chest x-ray can indicate pneumoperitoneum (air in the peritoneal cavity), retroperitoneum (space between the peritoneal cavity and the posterior abdominal wall), or diaphragmatic rupture, which are synonymous with abdominal penetrating trauma (2).

Treatment

Treatment of penetrating trauma depends on the injury location and the patient’s medical history. General treatment strategies include endotracheal tube intubation, mechanical ventilation, chest tube intubation, thoracotomy, pericardiocentesis, intravenous fluids, and blood therapy (2).

When hemodynamic instability, peritonitis, and pain persist, surgery may be indicated. All patients who sustain a gunshot or stab wound require physical rehabilitation and mental health support (2, 3, 10, 12). Prophylactic antibiotics are administered to prevent infection. Impaled objects are secured in place to prevent movement and are removed in the operating room. Bullets are removed unless it is determined that they may cause more injury upon removal, and wounds are debrided to prevent infection (2, 3, 10, 12).

A thoracotomy is a surgical procedure that allows access to the thoracic cavity to treat acute injuries to the thoracic organs (e.g., heart, lungs, esophagus). Thoracotomy is indicated for hemorrhagic shock when the patient requires multiple blood transfusions and massive hemothorax when chest tube output exceeds 1500 mL immediately upon placement or chest tube output exceeds 200 mL/hour for two to four hours. A thoracotomy is also an option when an impaled penetrating object causes cardiac tamponade, open pneumothorax, a persistent air leak due to tracheobronchial tree injury, or esophageal injury (2).

An exploratory laparotomy is indicated if the patient is experiencing hypotension, evisceration, peritoneal signs, or subdiaphragmatic air flow on a chest x-ray. The abdominal cavity is opened via a midline incision to help determine bleeding and perforation. An exploratory laparotomy is indicated if the patient is experiencing signs or symptoms of hypotension, peritonitis, evisceration, or bleeding of the rectum, gastrointestinal system, or genitourinary system (2).

Head and neck traumas require cervical spine immobilization and possible surgery for fractures. Extremity fractures require splinting or casting, and possible surgical interventions. Prophylactic tetanus vaccination is recommended in all patients who sustain a penetrating injury to prevent tetanus (2).

Complications

There are several complications that patients who sustain a gunshot or stabbing injury can experience. Some of these complications are specific to the location of the injury, such as traumatic brain injury, whereas others are more general, such as sepsis.

These complications include (2, 10):

• Sepsis
• Fistulas
• Tetanus
• Lead toxicity
• Open wounds
• Hemorrhagic shock
• Wound dehiscence
• Colostomy/ileostomy
• Traumatic brain injury
• Short bowel syndrome

Tetanus is associated with corrosive foreign bodies, such as a rusty knife blade, and lead toxicity can result from bullets with high lead content. Nurses must be diligent in monitoring patients for these complications and implementing strategic interventions to improve patient outcomes.

Patient Education

Nurses should teach patients that their penetrating injury resulted in a wound that requires meticulous care, and instructions for how to care for the wound should be provided.

The following information should be provided to these patients (4):

• Keep the dressing and area around it clean and dry.
• When changing the dressing, perform meticulous hand hygiene to prevent infection.
• Only use the wound cleansing agent that the healthcare provider recommended. Do not use additional products, such as hydrogen peroxide, unless approved by the healthcare provider.
• Do not apply lotions, creams, or alternative products to the wound unless approved by the healthcare provider. Doing so can result in tissue damage that can delay wound healing.
• Do not pull at stitches or staples, and do not attempt to remove them. They will either dissolve on their own, or the healthcare provider will remove them in 3 to 21 days.
• Penetrating wounds are dirty because the foreign object brings debris into the tissue; therefore, patients should take antibiotics as directed and should not stop their antibiotic treatment before they finish their prescription.
• Pain medications should be taken as directed, and these medications should not be shared with other individuals under any circumstances.
• Elevate the wound above the heart to reduce swelling. An ice pack can be placed over the bandage to help with swelling if approved by the healthcare provider.
• Take showers instead of baths because bath water becomes dirty, which can infect the wound. Soaking the wound in water can cause the wound to open.
• Either remove the dressing before showering or cover it with an occlusive dressing or plastic bag.
• If the healthcare provider has instructed, the wound can be gently cleansed with water while showering. The wound should not be scrubbed or exfoliated.
• After showering, gently pat the area around the wound with a clean, dry towel. Allow the area to air dry before applying a new, clean bandage.
• Notify the healthcare provider if the wound becomes more swollen and redder; red streaks appear near the wound; wound drainage increases; wound drainage becomes thick, tan, yellow, or green; and if a foul odor is detected.
• Notify the healthcare provider if a fever of 100°F (37.8°C) or higher is experienced for more than four hours.

Nurses should also educate patients about the signs and symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD) since these are common conditions in patients with penetrating trauma.

Signs and symptoms such as insomnia, hypersomnia, nightmares, anorexia, feelings of irritability and anger, feelings of fear, and constantly reliving the trauma in the patient’s mind are associated with PTSD. If the patient expresses suicidal ideation, another symptom of PTSD, they should be referred to a mental health provider immediately (4).

Prevention

Nurses play an important role in educating patients and community members about the ability of firearms and knives to cause harm. Injuries, death, and suicide by these methods are preventable.

The resources available to prevent gunshot and stabbing incidents are (6):

• Community outreach programs: Connecting populations at the highest risk for violence with community services helps reduce conflict within these communities. Gatekeeper programs train community members to identify those individuals who are at risk of suicide and to refer them to support services. Cleaning and maintaining vacant lots in metropolitan areas while promoting the use of safe urban green spaces reduces violence, improves the mental health of residents, and helps increase home values in impoverished areas. Maintaining safe routes to and from school for students by placing trained community members at key locations improves school attendance and reduces crime rates.
• Economic support services: Housing assistance, childcare subsidies, unemployment insurance, tax credits, and livable wages help lift families out of poverty and reduce their overall stress, which contributes to the reduction in crime and suicide rates.
• Hospital-based violence and suicide intervention programs: These programs provide family education, access to services, and support for those individuals and families affected by violence. These programs have been effective in reducing future violence and decreasing the rate of suicide and suicide attempts.
• Therapeutic approaches: Cognitive behavioral therapy and other mental health modalities support victims of violence and reduce the risk of future violence.
• Safe weapon storage: Utilizing lockboxes, safes, and trigger locks to prevent access to guns, knives, and other weapons helps decrease violence, especially among children. The Department of Veterans Affairs, American Foundation for Suicide Prevention, National Shooting Sports Foundation, American Academy of Pediatrics, and Defense Suicide Prevention Office provide resources for the safe storage of weapons.

The World Health Organization (WHO) provides the following resources to prevent violence (12):

• INSPIRE: seven strategies for preventing violence against children
• RESPECT women: preventing violence against women
• LIVE LIFE: suicide prevention implementation package
• SAFER: a world free from alcohol-related harms

Conclusion

Nurses may encounter patients with gunshot and stab wounds during their careers, particularly if they work in emergency, critical care, and surgical departments. Care of these patients is complex because gunshot and stab wounds are not only painful and take many months of recovery time, but the psychological trauma the patients endure can be very intense.

It is the nurse’s responsibility to not only care for the physical needs of these patients but also to address their psychological and emotional needs. Many patients who have experienced penetrating trauma require months of physical rehabilitation in addition to cognitive behavioral therapy and other mental health modalities if the patients develop post-traumatic stress disorder. Nurses should educate their patients about the community resources available to them to assist them during their recovery and to prevent the occurrence of these injuries in the future.

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