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Q&A: How Are Multiple Gunshot Wounds to the Chest Treated?

16 Jul

I got this fun question from my friend Dave Corbett.

Q: For my story, I need to know what someone with three small caliber wounds to his lungs, with a not-so-good time lapse before hospitalization (say 30-45 minutes) and internal bleeding, would face in the ICU. How would they treat him? I assume surgery to repair the internal wounds and stop the bleeding, but how does one do that with lung tissue? Post-op, what drugs would be used and what concerns and complications (heart attack, etc.) might he face? In the end, a friend helps smuggle him out of the hospital, because he’d rather die at home. Basically, I need the details to make the hospital scene vivid and credible.

David Corbett
http://www.davidcorbett.com

A: What happens to your shooting victim and how he is treated depends upon what injuries he received. A gunshot wound (GSW) can be a minor flesh wound or can be immediately deadly or anywhere in between. It all depends on the caliber and speed of the bullet and the exact structures it hits. A shot to the heart might kill instantly—or not. The victim could die in a few minutes or survive for days or could recover completely with proper medical care and surgery. It’s highly variable but ask any surgeon or ER doctor and they will tell you that it’s hard to kill someone with a gun. Even with a shot or two to the chest.

A small caliber, slow speed bullet, such as those fired by a .22 or .25 caliber weapon, are less likely to kill than would heavier, higher velocity bullets from .38, .357, or .45 caliber weapon. Also the type of bullet makes a difference. Jacketed or coated bullets penetrate more while hollow point or soft lead bullets penetrate less but do more damage as the bullet deforms on impact. All that is nice, but the bottom line is that whatever happens, happens. That is, a small, slow bullet might kill while a large, fast one might not.

Since in your victim the bullets penetrated the chest wall and damaged the lung, he would cough up blood, be very short of breath, and could die from bleeding into the lungs, basically drowning in his own blood. Or the lung could collapse and again cause pain and shortness of breath. But we have two lungs and unless the GSWs are to both lungs and both collapse, the victim would be able to breathe, speak, even run away, call for help, or fight off the attacker. If he’s tough, that is.

Most likely your guy would be very short of breath and cough and wheeze out blood in a fine mist or in larger droplets and even clots. He would quickly become very weak and dizzy, his blood pressure would drop, and he could slip into shock. With the injury to his lung, the oxygen content in his blood could dip to very low levels and he could lose consciousness if you want. Or not. Anything is possible. All this could happen in a very few minutes or over an hour or more, depending upon the rapidity of blood loss and the degree of injury to the lungs.

Once rescued, the paramedics might place an endotracheal (ET) tube into his lungs to help with breathing, start an IV to give fluids, and transport him to the hospital immediately. He would then be seen by a trauma or chest surgeon and immediately undergo surgery to remove the bullets (if possible) and to repair the damaged lung or whatever else was injured. The surgeon might simply repair the lung or he might have to remove one or more lobes (sections) of the injured lung. Each lung has three lobes—upper, middle, and lower. The left lung has a very small middle lobe, called the lingula, since its space is occupied by the heart.

After surgery, he would be on a ventilator for as long as needed but usually only overnight. We always try to remove ET tubes as quickly as we safely can since there are many complications if they remain in place for several days. Most commonly this is pneumonia. Also, being tied to an ET tube and a ventilator immobilizes the patient and sets him up for deep venous thrombosis (DVT—clots in the leg veins) and a pulmonary embolus (PE)—this is when the leg clot breaks free and travels to the lungs. Very dangerous and potentially deadly and a common occurrence in these situations.

He would have a chest tube (actually a thoracostomy tube but we call them chest tubes) in place. This is a flexible plastic tube that is inserted through the chest wall and slipped into the space between the chest wall and the lung. It is attached to a suction device and is used to evacuate air and any residual blood or body fluids from the chest cavity, which helps keep the lung inflated. Once the lung heals and can stay inflated on its own, the tube is pulled out. This could take a couple of days or up to a week. It’s highly variable.

He would be treated with antibiotics to prevent lung and wound infections and of course pain meds. Once he was off the ventilator, he would be mobilized from the bed to a chair as soon as possible. This helps prevent pneumonia, DVT, and PE. He would then begin respiratory therapy, initially with deep breathing exercises to help the lung stay inflated and heal more readily, and then to walking and strength building.

Most patients in this situation recover quickly without complications and go home in a week, rest there for a couple of weeks, return to part time work for a few weeks and be full speed by 3 to 4 months. Or he could have one of any number of complications and die. Or be permanently disabled. It all depends upon the nature of Injuries, the effectiveness of the treatment, and luck. None of this fits your guy though, since he plans to leave the hospital a bit early.

He could of course sneak out or could sign himself out of the hospital Against Medical Advice (we call it AMA) at any time after he was off the ventilator. If he did, they would give him antibiotics and pain meds and have him see his MD every couple of days for the first week or so. Then less frequently after that until he was well again. Or died peacefully at home as seems to be his plan.

 
32 Comments

Posted by on July 16, 2010 in Medical Issues, Q&A, Trauma

 

32 responses to “Q&A: How Are Multiple Gunshot Wounds to the Chest Treated?

  1. Erin

    July 16, 2010 at 9:36 pm

    Nice, specific information about bullet wounds to the chest. I’m glad to see this type of information out there, as I get so frustrated when I read books that get fairly basic medical information wrong. So I really appreciate your blog!

    I do have to make a correction, however. Technically, the left lung does only have two lobes (with two lobar bronchi vs. three lobar bronchi/three lobes in the right). The lingula is technically part of the upper lobe.

    In my experience, I have taken care of patients who have been shot and stabbed in the lungs that have required no surgery. In fact, in most cases I have seen, a chest tube is usually adequate for re-expansion of the lung unless a major airway (like a mainstem bronchus) or vessel is involved. Likewise, these patients usually don’t require intubation and mechanical ventilation, either.

    As you mentioned, I think it varies greatly and a lot depends on what the bullet hits other than the lung and how fit the person is to begin with. Elderly people or victims with prior illnesses will more likely have their breathing affected even by a “simple” bullet to lung tissue and might need to be placed on a ventilator. Of course, my experience is that most gunshot victims are usually young, strapping young men (sometimes women) who recover quickly from isolated injuries and leave the hospital after only a short stay.

    Now, we start to get other organs involved and that’s another issue all together!

    Thanks for posting these very informative posts!
    Erin (Respiratory Therapist)

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  2. D.P. Lyle, MD

    July 17, 2010 at 6:32 am

    To many anatomist the lingula is indeed part of the upper lobe–any many medical dictionaries define it as such–but to others it is the remnant of a middle lobe. Either way it is a distinct anatomical structure. Pneumonias that occur in that area re termed lingular pneumonia.

    Yes many GSWs to the chest are treated with only a chest tube–at least as the only surgical procedure—and this is particularly true with through and through GSWs—those where the bullet passes completely through the body and exits. But usually the lung requires surgical repair. Particularly with multiple GSWs.

    Good stuff. Thanks for your input.

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  3. Brenda

    July 17, 2010 at 1:55 pm

    I really appreciate your blog with the endless interesting topics like today’s as well as the opportunity to ask questions.

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  4. gary unsworth

    July 18, 2010 at 7:20 am

    This is a very interesting article, thank you. Wish I had found your site earlier, look forward to reading more.

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  5. Jonathan Quist

    July 18, 2010 at 12:24 pm

    Another minor detail, assuming the victim survives…

    After emergency surgery, I had a sore throat and hoarse voice as a side effect of the ET tube. In my case, this led to a respiratory infection as well…

    I don’t know how common this reaction is, but it was on the list of pre-op advisories I was given.

    So if your victim is a rock star, and wants to go on with the show a few days later, he’s likely lip-syncing his concert.

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    • D.P. Lyle, MD

      July 19, 2010 at 7:16 am

      That’s very common. The ET tube is passed into the trachea and thus must pass between the vocal cords that lie in the larynx–the voice box or Adam’s Apple. It irritates and causes swelling of the vocal cords and this is what makes your voice hoarse for a few hours to a day or so. Then as the swelling resolves the voice returns to normal. Most of the time. Sometimes permanent damage can occur. Not common but it does happen.

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  6. Beth

    July 21, 2010 at 3:39 pm

    Oh, I would definitely have my GSW victim initially have a dramatic and likely loud sucking chest wound and hear that grizly, life-sapping sucking sound with every attempted grueling breath! The trachea would be yanked to a side due to the pnemo/hemothorax and the neck veins distended like sailors’ ropes. And then along comes someone with a needle, a tube,a glove with a hole (for a one-way valve) and a container of water (rigged underwater seal) and the victim barely makes it on the rugged path to the trauma center on the back of a pickup truck while the weather is much too severe for the trauma copter.

    But that’s just me.

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  7. Beth

    July 21, 2010 at 3:49 pm

    Sorry, I didn’t address the question – IN hospital events. But my colleagues did such a good job of describing complications. But relapses of collapsed lung, infections, stridor from the infrequently (but it happens) swelling around the larynx from recently removed ET tube would make for a painful, noisy and ugly death at home. Oh, and previously, we all forgot the subcutaneous emphysema that swells up all the skin and makes the eyes like slits (from all the swelling) and makes the skin crackle like rice crispies when it is touched. That is because during chest trauma, the air seeps out of the lungs and into the space outside the chest cavity but under the skin and then expands with every breath. That swelling in the neck is enough to compromise the airway without an ET tube in place to keep it open.

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  8. Jonathan Quist

    July 22, 2010 at 9:13 am

    Beth, I think you’ve just helped a diabetic swear off rice crispie treats for life…

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  9. hugh brown

    December 8, 2011 at 2:16 pm

    Hi
    I was wondering what the hospital treatment would be for a point blank shot to the chest a couple of inches to the left of the heart with a .38 handgun? how long would they be in surgery – if surgery was necessary? when would they come round if they did have surgery, and how long till out of hospital?

    cheers – great site.

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    • D.P. Lyle, MD

      December 8, 2011 at 10:34 pm

      Depends on the exact nature of the wound and how well the treatment went. These types of injuries come in many flavors.

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  10. thomas

    February 2, 2012 at 10:25 pm

    Hi, quick question. Let’s assume you were shot with one bullet to the chest and it hit a lung. You were trapped on a plane for many hours (14 or so). What would the potential effects be on the person shot? We don’t want him to die and there is a doctor on the plane (with no medical kit). What could the doctor do to aid him and would it make sense to help the victim try to breathe the plane’s oxygen? Thanks so much! GREAT site! T

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    • D.P. Lyle, MD

      February 3, 2012 at 9:06 am

      Thomas—I don’t answer such questions here on my blog as I require certain information before I do so but you can submit them thru my website–be sure to include all the requested info.

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  11. Sally

    February 15, 2012 at 7:24 am

    Hi. Not sure if you can or will answer this question on the blog. I have a character who is shot and needs immediate surgery to remove the bullets. I want her to be doing fine for a little while, (a day or two) able to talk on the phone etc, to her kids while in the hospital.

    Then I need her to suddenly pass away due to complications. But of course I want it to be real, not contrived. Could you suggest ways that this might feasibly happen. Blood clot? pneumonia? anything?

    Thanks.

    Sally

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    • D.P. Lyle, MD

      February 15, 2012 at 12:07 pm

      No, I don’t answer questions on the blog but only thru my website. I require certain info be included with each question and this can be found on the site.

      Like

       
  12. Kendra

    May 2, 2012 at 1:50 am

    Thank you, I have been hunting for a simple layman terms explanation of a GSW to the chest that punctured a lung and it really helped me out with a story I’m writing. I definitely have you book marked for future reference

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  13. Marcy G. Dyer

    May 31, 2012 at 6:42 pm

    Dr. Lyle,
    I’m a nurse but have never worked trauma and was looking for specifics on GSW to the chest. Awesome! Thank you so much.

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  14. Brandi

    June 30, 2012 at 5:15 pm

    I came across this site searching for info about my children’s father, who has developed pneumonia four days after a gunshot tore through the upper left lung. He was shot with a 9 mm, and a second bullet hit his colon and stomach. He is puffy; swollen all around. They inserted a catheter, he has inflatable “balloons” around his legs to help prevent clotting, and his bed inflates and deflates from left to right to prevent bedsores. It is also worth mentioning that he has been placed in a medically induced coma to prevent him from waking. I thought he was just heavily drugged because he still had a strong gag reflex when they attempted to remove the chest tube and would occasionally flutter his eyelids, but apparently that’s still possible.

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  15. alyssa

    September 20, 2012 at 1:07 pm

    Hello my name is alyssa, my boyfriens sal 22yrs young died on sep.3.12 from a 45 caliber bullet straight through the heart…i just wanna know if he suffered or felt anything??? They say he collapsed about 4seconds after he got shot and turned white within seconds, but was still fighting for air…please i really wanna know. Thank u

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    • D.P. Lyle, MD

      September 20, 2012 at 6:30 pm

      Alyssa—I’m sorry for your loss but I do not comment on real life situations but rather only in the context of fiction writing.

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  16. M. Smith

    October 25, 2012 at 10:58 pm

    After reading this, I feel grateful and lucky that I was able to take three 9mm wounds to the left lung and survive without being able to go to a hospital. I have chest complications, but the fact that I can do most things without major problems is truly a miracle.

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  17. Michaela Otto

    December 11, 2012 at 5:19 pm

    What a great place the internet is! I’ve been looking for information about GSW to the abdomen, but the info I found wasn’t really to my liking so I tried something else. Came across this side and I found it very helpful for my story. Thank you so much for posting this!🙂

    Have to think though, my guy is only shot once, so I guess the symptoms may not be as strong as stated. But then anything is possible, right? Anyway, maybe I’ll find some more information on your website. I love that someone takes the time to help us writers. Thanks so much.

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    • D.P. Lyle, MD

      December 11, 2012 at 5:31 pm

      Yes almost anything can happen with GSWs and they can occur in any severity. The devil is in the details.
      Glad you like the site.

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  18. Keith Davies

    March 23, 2013 at 10:46 am

    Wow. I’m writing a screenplay in which I wanted a gunshot victim to come back into the story later, and needed to know whether that was feasible. I googled, and came across this. It’s brilliant!!! Thank you very much indeed. All the best. Keith Davies

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    • D.P. Lyle, MD

      March 23, 2013 at 12:59 pm

      Keith–Glad it helped. That’s always the hope.

      Like

       
  19. Candice Burger

    June 3, 2013 at 10:18 am

    Hi I hope you can help I want my main. Character sustains damage to his heart while sevring in the navy I still worling on the how but what I what to know is there a condition that could cause him illness or death if he wear to have his heart broken hoe it makes sence

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    • D.P. Lyle, MD

      June 3, 2013 at 10:33 am

      Candice–I don’t answer questions here as I require certain information before doing so. Visit my website and you will find the instructions for submitting questions.

      Like

       
  20. Lisa researching gunshot wounds

    December 29, 2013 at 5:54 pm

    I enjoyed your explanation of what could/should/might happen.

    Like

     
  21. simone

    March 12, 2014 at 11:03 am

    thank you for this article. i have a family with gun shot wound and it helps.

    Like

     
  22. Cainen Harris

    November 10, 2014 at 11:09 am

    Question, if a person were shot in the lung and paramedics were unavailable, how would you go about treating them?

    Like

     
    • D.P. Lyle, MD

      November 10, 2014 at 11:21 am

      I only answer story questions through my website (www.dplylemd.com) as I require certain information beforehand. Please visit my site and submit your question and the needed info that way.

      Like

       

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