Gunshot wounds as a part of firearm injuries contribute to a number of injury related deaths in urban cities and are increasingly becoming a major public health concern. These wounds are caused due to a propelled bullet, which transfers energy and causes variable degrees of damage.
Gunshot wounds to the abdomen are common, which usually involve abdominal structures like small intestine, colon, liver and other abdominal blood vessels. Gunshot wounds are the commonest cause of penetrating abdominal injuries, in which the abdominal cavity is injured by penetration of an injury causing weapon. These can cause bleeding and damage to internal organs.
Penetrating Gunshot Abdominal Wound and Its Impact
Penetrating gunshot abdominal wounds are usually medium to high density velocity injuries and can cause severe damage. The severity of these injuries depends on various factors like characteristics of the gun, particulars and location the bullet and is also influenced by the distance from which the bullet was fired.
Some bullets have a covering called jacket, which can cause deeper penetration. So the type and intensity of an injury depends on several factors and the characteristics of the injury need to be studied in detail. Gunshot wounds can appear as entry wounds, where bullet remains inside or both entry and exit wounds, where the bullet passes through the body.
Abdominal injuries caused by gunshot wounds are mainly due to crushing of tissues and penetration into the vital organs, followed by bleeding. In general, it is found that injury to the centre of major organs like liver can cause more bleeding and an injury to the right side can be more serious. The intestines and the stomach may get injured causing rupture and the spilling of their contents increase the risk of infection. Wounds in the flank region are more likely to affect organs like kidneys, bladder, ureters, duodenum, pancreas, colon, rectum and major abdominal blood vessels.
Evaluation and Assessment of Gunshot Wound to The Abdomen
The emergency medical team needs to meticulously assess cases of abdominal gunshot wounds, which begins at the scene itself. Assessment and information about the location of the gunshot wound, number of gunshots heard by the people in the surrounding and the victim’s position when the gun was shot, help to determine the path of the bullet and the possible abdominal injuries caused.
The amount of blood lost at the scene can give an idea of the extent of injuries sustained but needs proper evaluation. The nature of bleeding may help to identify any involvement of major blood vessels. It is important to assess the initial level of consciousness of the patient and to note the signs of life, which include pupil response, heart rate, pulse and respiration. As an initial assessment these parameters along with signs of external bleeding are noted.
In a patient, who is awake, signs like abdominal pain, referred pain to shoulders or other areas, rebound tenderness and other characteristics are physically examined. In a patient who is unresponsive, abdominal bruising and distension may be present due to internal bleeding.
Other signs that are evaluated to determine severity of the wound and to guide in the decision of surgical intervention include low blood pressure, increased or decreased respiratory rate and a narrow pulse pressure. Other signs of insufficient end organ perfusion may indicate substantial intra-abdominal injury and may call for surgical intervention.
Investigations including complete laboratory profile like blood count, electrolyte, creatinine, calcium and glucose levels and arterial blood gas analysis. Imaging studies like X-rays - chest and abdomen, ultrasound can be very useful in determining the extent of injuries and organ involvement. Abdominal CT scan is of great value in working up for intra abdominal injuries and to the flank region, liver and spleen involvement. Other studies like diagnostic peritoneal lavage, laparoscopy, laparotomy and others may be used depending on the injury and patient’s condition.
Treatment of Gunshot Wound to The Abdomen
As many abdominal gunshot wounds lead to severe bleeding, deaths can occur before hospitalization of the patient. The emergency care delivered at the scene, initial assessment of the patient and rapid transportation to an emergency medical setting or trauma centre plays an important role.
Intravenous fluid administration is considered according to the patient’s condition and the duration of the journey; immediate oxygen supplementation may be given. Treatment may include direct pressure to the injured part, bandaging or dressing. In hemodynamically stable patient, the treatment approach depends on the affected area of the abdomen.
In case of series of gunshot wounds, there are chances of injuries to multiple organs and vascular structures; hence controlling hemorrhage is primarily important. Operative procedures are decided and accordingly performed if required. Special care and consideration may be required in case of women and pregnant ladies sustaining gunshot wounds to the abdomen.
Prognosis of Gunshot Wound to The Abdomen
Gunshot wounds with intra-abdominal injuries are more of concern. A poor prognosis is indicated by low blood pressure at the time of hospital admission, multiple organs injuries and large volumes of blood loss requiring excessive blood replacement. Many deaths from gunshot wounds to abdomen also occur due to secondary shock.