1. The Science and Care for Ballistics Trauma
Thomas P. Beers
EMS Coordinator
Cleveland Clinic

2. Overview Introduction to Firearms Physics of Penetrating Trauma
Specific Tissue/Organ Injuries
Special Concerns with Penetrating Trauma

3. Introduction to Firearms in America
12 BILLION rounds of ammunition are sold in the US annually
The CDC estimates ~52,000 deliberate and ~23,000 accidental no-fatal shootings annually
~30,000 fatal gun shot wounds annually in the United States
Firearms are used 2 to 2.5 million times a year for legal self defense

4. CDC Statistics

5. Physics of Penetrating Trauma
Recall Kinetic Energy Equation
Greater the mass the greater the energy
Double mass = double KE
Greater the speed the greater the energy
Double speed = 4x increase KE
(continued)

6. Physics of Penetrating Trauma
Small & Fast bullet can cause greater damage than large and slow.
Different bullets of different weights traveling at different speeds cause different injuries
Low Energy/Low Velocity
Knives and arrows
Medium Energy/Medium Velocity Weapons
Handguns, shotguns, low-powered rifles
mps
High Energy/High Velocity
Assault Rifles
600-1,000 mps
(continued)

8. Colt .357 M4

11. Physics of Penetrating Trauma
Bullet spins as it travels down barrel
Rifling in barrel
Allows bullet to travel straighter
Bullet departs barrel, spinning with a slight wobble or yaw
Weapon forced backward and absorbs energy
Recoil
(continued)

12. Physics of Penetrating Trauma
Remainder of energy propels bullet forward at a high rate of speed.
Trajectory is being pulled down by gravity
As bullet strikes object, it slows and energy is transferred to object.
Law of Conservation of Energy

13. Ballistics
Study of the characteristics of projectiles in motion and effects upon objects impacted
Factors affecting energy exchange between a projectile and body tissue
Velocity
Profile
Stability
Expansion & Fragmentation
Secondary Impacts

14. Aspects of Ballistics Velocity ESCAPE VELOCITY Causes Trajectory
Faster = straighter trajectory
Slower = more curved due to gravity
ESCAPE VELOCITY

15. Aspects of Ballistics Profile
Portion of bullet you see as it travels towards you
Larger profile = greater energy exchange
Caliber
Diameter of a bullet (ID of gun)
0.22 caliber = 0.22 inches
Bullets become unstable as they pass from one medium to another.

17. Aspects of Ballistics Profile
Portion of bullet you see as it travels towards you
Larger profile = greater energy exchange
Caliber
Diameter of a bullet (ID of gun)
0.22 caliber = 0.22 inches
Bullets become unstable as they pass from one medium to another.

18. Aspects of Ballistics Stability
Bullet length increases bullet tumbling
Can reduce the accuracy of the shot
Reduced by Rifling in barrel (spinning)
Yaw
Gyroscopic effect on the center axis of the bullet that reduces tumbling
Tumbling of bullet once it strikes object
Greater tissue damage

19. Bullet Stability

20. Aspects of Ballistics Expansion & Fragmentation
Results in increased profile
Mushrooming
Initial impact forces may result in fragmenting
Greater tissue damage

25. Aspects of Ballistics Secondary Impacts Shape
Bullet striking other objects can cause yaw and tumble
Body Armor (Kevlar)
Transmits energy throughout entire vest resulting in blunt trauma
Myocardial Contusion
Pulmonary Contusion
Rib Fractures
Shape
Handgun Ammunition = Blunt = Tumble
Rifle Ammunition = Pointed = Piercing

26. Specific Weapon Characteristics
Handguns
Small caliber, short barrel, medium-velocity
Effective at close range
Severity of injury based upon organs damaged
Rifle
High-velocity, longer barrel, large caliber
Increased accuracy at far distances
Assault Rifles
Large magazine, semi- or full-automatic
Similar injury to hunting rifles
Multiple wounds

27. Specific Weapon Characteristics
Shotgun
Slug or pellets at medium velocity
00 (1/3”) to #9 (pin head sized)
Larger the load, the smaller the number of projectiles
Deadly at close range
Knives & Arrows
Low-energy & low-velocity
Damage related to depth and angle of attack
Movement of the victim can increase damage

32. Damage Pathway Projectile Injury Process Tip impacts tissue
Tissue pushed forward and to the side
Tissue collides with adjacent tissue
Shock wave of pressure forward and lateral
Moves perpendicular to bullet path
Rapid compression, crushes and tears tissue
Cavity forms behind bullet pulling in debris with suction.

33. Damage Pathway Direct Injury Pressure Shock Wave Temporary Cavity
Damage done as the projectile strikes tissue
Pressure Shock Wave
Human tissue is semi-fluid
Solid and dense organs are damaged greatly
Temporary Cavity
Due to cavitation
Permanent Cavity
Due to seriously damaged tissue
Zone of Injury
Area that extends beyond the area of permanent injury

34. Ballistics Cavitation

36. Low-Velocity Wounds Objects Injury limited to tissue impacted
Knives, Ice-picks, Arrows
Flying objects or debris
Injury limited to tissue impacted
Object pathway
Object twisting or moved
Oblique angle
Attacker Characteristics
Males: outward and crosswise
Females: overhand and downward

40. Specific Tissue & Organ Injuries
Density of tissue affects the efficiency of energy transmission
Resiliency
Strength and elasticity of an object
Connective Tissue
Absorbs energy and limits tissue damage
Organs
Solid Organs
Dense and low resilience
Hollow Organs
Fluid filled: transmit energy = increased damage
Air filled: absorbs energy = less damage

41. Specific Tissue & Organ Injuries
Lungs
Air in lung absorbs energy
Tissue is compressed and rebounds
Pneumothorax or hemothorax can result
Bone
Resists displacement until it shatters
Alters projectile path

42. General Body Regions Extremities Abdomen (Includes Pelvis) Thorax
Injury limited to resiliency of tissue
60-80% of injuries with <10% mortality
Abdomen (Includes Pelvis)
Highly susceptible to injury and hemorrhage
Bowel perforation: hrs peritoneal irritation
Thorax
Rib impact results in explosive energy
Heart & great vessels have extensive damage due to lack of fluid compression
Any large chest wound compromises breathing

43. General Body Regions Neck Head Damages Trachea and Blood Vessels
Neurological problems
Sucking neck wound
Head
Cavitational energy trapped inside skull
Serious bleeding and lethal

44. Wound Characteristics
Entrance Wounds
Size of bullet profile for non-deforming bullets
Deforming projectiles may cause large wounds
Close Range
Powder Burns (Tattooing of powder)
1-2 mm circle of discoloration
Localized subcutaneous emphysema
Exit Wounds
Appears to be “Blown” outward
Pressure wave

47. Special Concerns with Penetrating Trauma
Scene Size-Up
Law-Enforcement
DO NOT ENTER UNTIL SCENE IS SAFE!
Weapons: Victim or Assailant
Assailants
IF A CRIME SCENE
DOCUMENT
DO NOT DISTURB EVIDENCE
RETAIN CLOTHING, ETC
LIMIT PERSONNEL INVOLVEMENT

48. Special Concerns with Penetrating Trauma
Penetrating Wound Assessment
Internal Organ Injury Potential
Entrance & Exit Wounds
PROVIDE RAPID TRANSPORT FOR ANY GSW TO HEAD, CHEST, OR ABDOMEN. TREAT AGGRESIVELY FOR SHOCK!!

49. Special Concerns with Penetrating Trauma
Penetrating Wound Care
Facial Wounds
Difficult intubations
Depress chest
Pass ET through bubbling tissue
Consider LMA and Combitube
Consider Cricothyreotomy & Cricothyreostomy
Chest Wounds
Pneumothorax
2/3” the diameter of the trachea or larger to entrain air
3-sided occlusive dressing
Needle Decompress
Pericardial Tamponade

51. Special Concerns with Penetrating Trauma
Impaled Objects
Low-energy
Dangerous to remove
DO NOT REMOVE
UNLESS
In Cheek
Interferes with CPR: ASSESS!!!

53. Proliferation of Hemostatic Bandages
QuikClot
Hemcon
Celox

54. Use of Pre-hospital Tourniquets
Extensively research in current GWOT

55. The Importance of Pre-Hospital
The Golden Hour and the Platinum 10
The importance of GCS
Quick fluid challenge and airway maintained will make the difference …
…and that is done by EMS

56. Special Concerns with Penetrating Trauma
Points to Remember…
ABC’s always, protect airway at all costs with early use of adjuncts.
Treat ALL possible systems damaged
Do not get “tunnel vision” based on entrance and exit wounds

57. Summary Remember that it is not the bullet…it’s the energy!
What you see is not always what you get!
The most important thing to remember is your safety
And finally…

58. Guns don’t kill people, gaping holes in vital organs kill people